Healthcare Provider Details

I. General information

NPI: 1407989742
Provider Name (Legal Business Name): KSHAMA JAWALEKAR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 09/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 E PONCE DE LEON AVE SUITE 120
DECATUR GA
30030-2543
US

IV. Provider business mailing address

150 E PONCE DE LEON AVE SUITE 120
DECATUR GA
30030-2543
US

V. Phone/Fax

Practice location:
  • Phone: 800-998-5859
  • Fax: 404-378-7460
Mailing address:
  • Phone: 800-998-5859
  • Fax: 404-378-7460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number2008016361
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number12836
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: