Provider Demographics
NPI:1912984808
Name:AL HUSEIN, IYAD (MD)
Entity Type:Individual
Prefix:
First Name:IYAD
Middle Name:
Last Name:AL HUSEIN
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 1:301 OSIGIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-8953
Mailing Address - Country:US
Mailing Address - Phone:478-971-2130
Mailing Address - Fax:478-971-2132
Practice Address - Street 1:301 OSIGIAN BLVD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-8953
Practice Address - Country:US
Practice Address - Phone:478-971-2130
Practice Address - Fax:478-971-2132
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT037371207Q00000X, 207QG0300X
GA055080207QG0300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA592585683AMedicaid
CT001373711Medicaid
CT080001283Medicare ID - Type Unspecified
CT001373711Medicaid
GA08CBBMMMedicare PIN