Healthcare Provider Details

I. General information

NPI: 1699741991
Provider Name (Legal Business Name): SURESH ENJETI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 08/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6325 HOSPITAL PKWY
DULUTH GA
30097
US

IV. Provider business mailing address

6325 HOSPITAL PKWY
DULUTH GA
30097-5775
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-3261
  • Fax: 404-778-5660
Mailing address:
  • Phone: 404-778-3261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number026108
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: