Healthcare Provider Details

I. General information

NPI: 1356559322
Provider Name (Legal Business Name): DANWANTRY MEDICAL & IMAGING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 11/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4961 BUFORD HWY SUITE 102
CHAMBLEE GA
30341-3503
US

IV. Provider business mailing address

PO BOX 1527
DUBLIN GA
31040-1527
US

V. Phone/Fax

Practice location:
  • Phone: 478-998-1471
  • Fax:
Mailing address:
  • Phone: 478-274-1100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number025580
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number025580
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number025580
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number025580
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number025580
License Number StateGA
# 6
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number025580
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. RAGHAVA A. BHASKARAN
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 478-998-1471