Basic Information
| Provider Information | |||||||||
| NPI: | 1639173248 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HIMOT | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 55 WHITCHER ST NE | ||||||||
| Address2: | STE 460 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704277389 | ||||||||
| FaxNumber: | 7704272845 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 WHITCHER ST NE | ||||||||
| Address2: | STE 460 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704277389 | ||||||||
| FaxNumber: | 7704272845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2005 | ||||||||
| LastUpdateDate: | 08/01/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 018388 | GA | N | Other Service Providers | Specialist | 207RN0300X | GA018388 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 000135231F | 05 | GA | MEDICAID | 000135231T | 05 | GA | MEDICAID | 000135231U | 05 | GA | MEDICAID | 000135231H | 05 | GA | MEDICAID | 000135231Y | 05 | GA | MEDICAID | 000135231L | 05 | GA | MEDICAID | 000135231V | 05 | GA | MEDICAID | 000135231M | 05 | GA | MEDICAID | 00135231A | 05 | GA | MEDICAID | 000135231J | 05 | GA | MEDICAID | 000135231K | 05 | GA | MEDICAID | 000135231W | 05 | GA | MEDICAID | 000135231R | 05 | GA | MEDICAID | 000135231X | 05 | GA | MEDICAID | 000135231E | 05 | GA | MEDICAID | 000135231S | 05 | GA | MEDICAID |