Provider Demographics
NPI:1366483844
Name:MOMIN, MUSHARAF (MD)
Entity type:Individual
Prefix:
First Name:MUSHARAF
Middle Name:
Last Name:MOMIN
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 1:130 EAGLE SPRING CT STE A
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7252
Mailing Address - Country:US
Mailing Address - Phone:678-759-2278
Mailing Address - Fax:404-783-1767
Practice Address - Street 1:130 EAGLE SPRING CT STE A
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7252
Practice Address - Country:US
Practice Address - Phone:678-759-2278
Practice Address - Fax:678-782-3260
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA55831207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAI41851Medicare UPIN
GA11SCFMLMedicare ID - Type Unspecified