Healthcare Provider Details

I. General information

NPI: 1922437375
Provider Name (Legal Business Name): PRABHAVA BAGLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2013
Last Update Date: 03/13/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 JESSE HILL JR DR SE
ATLANTA GA
30303-3031
US

IV. Provider business mailing address

80 JESSE HILL JR DR SE
ATLANTA GA
30303-3031
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-4889
  • Fax: 404-778-0826
Mailing address:
  • Phone: 404-778-4889
  • Fax: 404-778-0826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME125924
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME125924
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number98134
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: