Healthcare Provider Details

I. General information

NPI: 1184289993
Provider Name (Legal Business Name): KISHORE SATHIRAJU DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2019
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 COLLIER RD NW STE 2000
ATLANTA GA
30309-1734
US

IV. Provider business mailing address

300 W 27TH ST
LUMBERTON NC
28358-3075
US

V. Phone/Fax

Practice location:
  • Phone: 404-350-1122
  • Fax:
Mailing address:
  • Phone: 910-671-5000
  • Fax: 910-738-3730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number94184
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: