Healthcare Provider Details

I. General information

NPI: 1386644961
Provider Name (Legal Business Name): MANJUSHREE GHOSE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 10/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1595 CLEVELAND AVE
EAST POINT GA
30344-3200
US

IV. Provider business mailing address

75 PIEDMONT AVE SUITE 700
ATLANTA GA
30303-2544
US

V. Phone/Fax

Practice location:
  • Phone: 404-616-2886
  • Fax: 404-209-1769
Mailing address:
  • Phone: 404-616-1776
  • Fax: 404-241-7162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number042827
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number042827
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: