Provider Demographics
NPI:1588944771
Name:CLARKSTON FAMILY MEDICINE
Entity type:Organization
Organization Name:CLARKSTON FAMILY MEDICINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MINBH THO
Authorized Official - Middle Name:
Authorized Official - Last Name:HUYNH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-299-7534
Mailing Address - Street 1:3603 W HILL ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30021-1207
Mailing Address - Country:US
Mailing Address - Phone:404-299-7534
Mailing Address - Fax:404-299-0608
Practice Address - Street 1:3603 W HILL ST
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:GA
Practice Address - Zip Code:30021-1207
Practice Address - Country:US
Practice Address - Phone:404-299-7534
Practice Address - Fax:404-299-0608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-19
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA019886305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0085000391GMedicaid