Healthcare Provider Details

I. General information

NPI: 1609010800
Provider Name (Legal Business Name): SANJAY VINJAMARAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2009
Last Update Date: 08/28/2020
Certification Date: 08/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 NORTHSIDE BLVD STE 4600
CUMMING GA
30041-7658
US

IV. Provider business mailing address

1100 JOHNSON FERRY RD STE 510
SANDY SPRINGS GA
30342-1743
US

V. Phone/Fax

Practice location:
  • Phone: 770-205-5292
  • Fax: 770-205-5291
Mailing address:
  • Phone: 404-419-1165
  • Fax: 404-419-1179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number84344
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: