Provider Demographics
NPI:1740464189
Name:KOOSHKABADI, MOHAMMAD (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:
Last Name:KOOSHKABADI
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 1:229 PEACHTREE ST NE STE 1200
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30303-1620
Mailing Address - Country:US
Mailing Address - Phone:404-874-1788
Mailing Address - Fax:404-872-4589
Practice Address - Street 1:229 PEACHTREE ST NE STE 1200
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303
Practice Address - Country:US
Practice Address - Phone:404-874-1788
Practice Address - Fax:404-872-4589
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-20
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA058053207RC0000X, 207RC0001X
GA58053207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA616446282FMedicaid
GA616446282VMedicaid
GA202I066611Medicare PIN