Provider Demographics
NPI:1831622984
Name:KHAMISSI SOBI, MALI
Entity type:Individual
Prefix:
First Name:MALI
Middle Name:
Last Name:KHAMISSI SOBI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1268 RIDGECREST LN SE
Mailing Address - Street 2:APT/SUITE
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-2664
Mailing Address - Country:US
Mailing Address - Phone:770-875-6870
Mailing Address - Fax:
Practice Address - Street 1:4787 AUSTELL RD
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-2001
Practice Address - Country:US
Practice Address - Phone:770-875-6870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-05
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA82852207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA82852OtherGA MEDICAL LICENSE