Basic Information
| Provider Information | |||||||||
| NPI: | 1568517720 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TARIQ JAVED, M.D., P.C. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 631 CAMPBELL HILL ST NW | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704220444 | ||||||||
| FaxNumber: | 7704224412 | ||||||||
| Practice Location | |||||||||
| Address1: | 631 CAMPBELL HILL ST NW | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704220444 | ||||||||
| FaxNumber: | 7704224412 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2007 | ||||||||
| LastUpdateDate: | 02/08/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DEAN | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7704220444 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 003649 | GA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist | 174400000X | 34376 | GA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 100001357A | 05 | GA | MEDICAID | 00349499A | 05 | GA | MEDICAID | 00470148B | 05 | GA | MEDICAID |