Healthcare Provider Details

I. General information

NPI: 1104575638
Provider Name (Legal Business Name): PHILLIP LUIS ANJUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2022
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 JESSE HILL JR DR SE
ATLANTA GA
30303-3049
US

IV. Provider business mailing address

555 CASTRO ST
MOUNTAIN VIEW CA
94041-2009
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-7777
  • Fax:
Mailing address:
  • Phone: 650-903-2134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number99601
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number201460
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: