Provider Demographics
NPI:1083606727
Name:AMIN, DIPAKKUMAR PREMANAND (MD)
Entity type:Individual
Prefix:MR
First Name:DIPAKKUMAR
Middle Name:PREMANAND
Last Name:AMIN
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 1:470 VALLEY ST STE 200
Mailing Address - Street 2:
Mailing Address - City:BALL GROUND
Mailing Address - State:GA
Mailing Address - Zip Code:30107-4068
Mailing Address - Country:US
Mailing Address - Phone:770-737-2770
Mailing Address - Fax:770-737-2406
Practice Address - Street 1:470 VALLEY ST STE 200
Practice Address - Street 2:
Practice Address - City:BALL GROUND
Practice Address - State:GA
Practice Address - Zip Code:30107-4068
Practice Address - Country:US
Practice Address - Phone:770-737-2770
Practice Address - Fax:770-737-2406
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA94394207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0878804Medicaid
OHF30455Medicare UPIN
OH0878804Medicaid