Provider Demographics
NPI:1871212563
Name:MOMIN, TAKKI (MD)
Entity type:Individual
Prefix:DR
First Name:TAKKI
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 1:3069 AMWILER RD STE 1
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30360-2825
Mailing Address - Country:US
Mailing Address - Phone:404-910-9116
Mailing Address - Fax:
Practice Address - Street 1:3069 AMWILER RD STE 1
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30360-2825
Practice Address - Country:US
Practice Address - Phone:404-910-9116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11D2261376247ZC0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician