Healthcare Provider Details

I. General information

NPI: 1891794459
Provider Name (Legal Business Name): KETAN CHHAGAN DALSANIA DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2005
Last Update Date: 01/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 17TH ST
COLUMBUS GA
31901-3500
US

IV. Provider business mailing address

705 17TH ST STE 200
COLUMBUS GA
31901-3507
US

V. Phone/Fax

Practice location:
  • Phone: 706-322-7884
  • Fax: 706-322-7884
Mailing address:
  • Phone: 706-322-7884
  • Fax: 706-660-2142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number287
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD001033
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: