Healthcare Provider Details

I. General information

NPI: 1639968019
Provider Name (Legal Business Name): DISA RATHORE DO, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2025
Last Update Date: 05/02/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1469 LANEY WALKER BLVD
AUGUSTA GA
30912-0002
US

IV. Provider business mailing address

5335 NW 190TH LN
MIAMI GARDENS FL
33055-5323
US

V. Phone/Fax

Practice location:
  • Phone: 796-721-7005
  • Fax:
Mailing address:
  • Phone: 786-247-9614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number17460
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: