Provider Demographics
NPI:1275583825
Name:BAKHTIARY, HAMID HARRISON (MD)
Entity type:Individual
Prefix:
First Name:HAMID
Middle Name:HARRISON
Last Name:BAKHTIARY
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 1:3950 AUSTELL RD
Mailing Address - Street 2:BOX 22
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1121
Mailing Address - Country:US
Mailing Address - Phone:470-732-4022
Mailing Address - Fax:470-732-4023
Practice Address - Street 1:3950 AUSTELL RD
Practice Address - Street 2:BOX 22
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1121
Practice Address - Country:US
Practice Address - Phone:470-732-4022
Practice Address - Fax:470-732-4023
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053345207R00000X
GA53345208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA220635671EMedicaid
GA220635671EMedicaid
GA11SCFRBMedicare ID - Type Unspecified