Healthcare Provider Details

I. General information

NPI: 1255483756
Provider Name (Legal Business Name): PAUL LOUIS DESANDRE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 03/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1670 CLAIRMONT RD
DECATUR GA
30033-4004
US

IV. Provider business mailing address

1670 CLAIRMONT RD
DECATUR GA
30033-4004
US

V. Phone/Fax

Practice location:
  • Phone: 404-321-6111
  • Fax: 404-417-1510
Mailing address:
  • Phone: 404-251-8921
  • Fax: 404-688-6351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PH0002X
TaxonomyHospice and Palliative Medicine (Emergency Medicine) Physician
License Number64528
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number64528
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: