Healthcare Provider Details

I. General information

NPI: 1336494624
Provider Name (Legal Business Name): ANJUM ARA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2012
Last Update Date: 07/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

997 SAINT SEBASTIAN WAY
AUGUSTA GA
30912-2613
US

IV. Provider business mailing address

1499 WALTON WAY STE 1400 ATTN: D. RAIFORD
AUGUSTA GA
30901-2603
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-6597
  • Fax: 706-721-6602
Mailing address:
  • Phone: 706-828-8401
  • Fax: 706-722-7235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number075367
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: