Healthcare Provider Details

I. General information

NPI: 1699933226
Provider Name (Legal Business Name): SHREYA RAJA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2008
Last Update Date: 04/26/2024
Certification Date: 04/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1670 CLAIRMONT RD
DECATUR GA
30033-4004
US

IV. Provider business mailing address

3151 WINDSOR LAKE DR NE
BROOKHAVEN GA
30319-2374
US

V. Phone/Fax

Practice location:
  • Phone: 404-321-6111
  • Fax:
Mailing address:
  • Phone: 404-432-5288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number66625
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number66625
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: