Provider Demographics
NPI:1194701839
Name:NIKNAFS, MOSTAFA (DPM)
Entity type:Individual
Prefix:
First Name:MOSTAFA
Middle Name:
Last Name:NIKNAFS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:DR
Other - First Name:M.NIKNAFS
Other - Middle Name:
Other - Last Name:PODIATRIST PC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1010 PRINCE AVE
Mailing Address - Street 2:SUITE 180
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-5805
Mailing Address - Country:US
Mailing Address - Phone:706-548-2544
Mailing Address - Fax:
Practice Address - Street 1:1010 PRINCE AVE
Practice Address - Street 2:SUITE 180
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-5805
Practice Address - Country:US
Practice Address - Phone:706-548-2544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA528213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00299637BMedicaid
GA4201900002OtherDME
GA00299637BMedicaid
GA48SCBQKMedicare ID - Type Unspecified