Healthcare Provider Details

I. General information

NPI: 1205126851
Provider Name (Legal Business Name): ANJAN DEKA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2011
Last Update Date: 07/21/2022
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 NORTHSIDE CHEROKEE BLVD STE 190
CANTON GA
30115-8018
US

IV. Provider business mailing address

9200 W WISCONSIN AVENUE DIVISON OF CARDIOLOGY
MILWAUKEE WI
53226-3522
US

V. Phone/Fax

Practice location:
  • Phone: 470-639-6250
  • Fax: 770-345-0712
Mailing address:
  • Phone: 414-955-5611
  • Fax: 414-456-6515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number6745320
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036.135578
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number82555
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: