Healthcare Provider Details

I. General information

NPI: 1609087527
Provider Name (Legal Business Name): DAVID ROMESH PERSAUD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 01/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

772 MADDOX DR STE. 122
EAST ELLIJAY GA
30540-8196
US

IV. Provider business mailing address

165 BLUE RIDGE OVERLOOK
BLUE RIDGE GA
30513-4431
US

V. Phone/Fax

Practice location:
  • Phone: 706-635-6898
  • Fax: 706-635-6888
Mailing address:
  • Phone: 706-946-5600
  • Fax: 706-374-7628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number70703
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: