Provider Demographics
NPI:1588719470
Name:MASTER, MOIZ VASIM (MD)
Entity type:Individual
Prefix:DR
First Name:MOIZ
Middle Name:VASIM
Last Name:MASTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MOIZ
Other - Middle Name:VASIM
Other - Last Name:MASTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4046 GOLD MILL RDG
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-6531
Mailing Address - Country:US
Mailing Address - Phone:678-383-4362
Mailing Address - Fax:
Practice Address - Street 1:12 SAMMY MCGHEE BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143-7711
Practice Address - Country:US
Practice Address - Phone:706-253-3344
Practice Address - Fax:706-253-3348
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054088207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH09084Medicare UPIN