Provider Demographics
NPI:1487746483
Name:KAZI, MOINUDDIN (MD)
Entity type:Individual
Prefix:MR
First Name:MOINUDDIN
Middle Name:
Last Name:KAZI
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 1:2803 PRIESTCLIFF DR
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080
Mailing Address - Country:US
Mailing Address - Phone:770-434-5061
Mailing Address - Fax:
Practice Address - Street 1:4480 N SHALLOWFORD RD
Practice Address - Street 2:STE 200
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338
Practice Address - Country:US
Practice Address - Phone:770-455-8285
Practice Address - Fax:770-350-8973
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA 042868207Q00000X
GA042868207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000776432EMedicaid
GAG63629Medicare UPIN
GA000776432EMedicaid