Healthcare Provider Details

I. General information

NPI: 1942995808
Provider Name (Legal Business Name): SEAN VALLABH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2023
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST # HB-5025
AUGUSTA GA
30912-3115
US

IV. Provider business mailing address

1301 SILVER BEACH WAY
RALEIGH NC
27606-4892
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-2131
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: