Provider Demographics
NPI:1932190477
Name:KHODAKARAM, MOHSEN (MD)
Entity type:Individual
Prefix:DR
First Name:MOHSEN
Middle Name:
Last Name:KHODAKARAM
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 1:2033 BUFORD HWY
Mailing Address - Street 2:SUITE 109
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-8802
Mailing Address - Country:US
Mailing Address - Phone:770-945-4800
Mailing Address - Fax:770-271-8428
Practice Address - Street 1:2721 BUFORD HWY
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-3507
Practice Address - Country:US
Practice Address - Phone:770-945-4800
Practice Address - Fax:770-271-8428
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051673207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA699854934AMedicaid
GA11BDXGTMedicare ID - Type Unspecified