Provider Demographics
NPI:1366534661
Name:YAZDI, FARHAD M (DO)
Entity type:Individual
Prefix:
First Name:FARHAD
Middle Name:M
Last Name:YAZDI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 520
Mailing Address - Street 2:
Mailing Address - City:OAKWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30566
Mailing Address - Country:US
Mailing Address - Phone:770-287-1140
Mailing Address - Fax:770-534-2700
Practice Address - Street 1:4205 MUNDY MILL PL
Practice Address - Street 2:SUITE 1
Practice Address - City:OAKWOOD
Practice Address - State:GA
Practice Address - Zip Code:30566-2566
Practice Address - Country:US
Practice Address - Phone:770-287-1140
Practice Address - Fax:770-534-2700
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047381207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00845446CMedicaid
GA00845446CMedicaid
GA08BBTGMMedicare ID - Type Unspecified