Provider Demographics
NPI:1740212240
Name:HISAMUDDIN, MOHSIN M (MD)
Entity type:Individual
Prefix:
First Name:MOHSIN
Middle Name:M
Last Name:HISAMUDDIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2655 DALLAS HWY SW
Mailing Address - Street 2:SUITE 340
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-2597
Mailing Address - Country:US
Mailing Address - Phone:678-797-9800
Mailing Address - Fax:678-797-9801
Practice Address - Street 1:2655 DALLAS HWY SW
Practice Address - Street 2:SUITE 340
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-2597
Practice Address - Country:US
Practice Address - Phone:678-797-9800
Practice Address - Fax:678-797-9801
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045498207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000800401DMedicaid
GA000800401CMedicaid
BH9794151OtherDEA
G76166Medicare UPIN
GA000800401CMedicaid