Healthcare Provider Details

I. General information

NPI: 1790706596
Provider Name (Legal Business Name): RAJESHKUMAR MOTILAL MINIYAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 09/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 SHIELDS RD
DALTON GA
30720-5013
US

IV. Provider business mailing address

140 THREE RIVERS DR NE
ROME GA
30161-4999
US

V. Phone/Fax

Practice location:
  • Phone: 706-278-6628
  • Fax: 706-278-6650
Mailing address:
  • Phone: 706-232-1300
  • Fax: 706-232-1039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number051597
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: