Healthcare Provider Details

I. General information

NPI: 1205828696
Provider Name (Legal Business Name): RAKESH KUMAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 10/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 SPARTA HWY
EATONTON GA
31024-6093
US

IV. Provider business mailing address

PO BOX 4150
EATONTON GA
31024-4150
US

V. Phone/Fax

Practice location:
  • Phone: 706-485-2621
  • Fax: 706-485-9354
Mailing address:
  • Phone: 706-485-2621
  • Fax: 706-485-9354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22807
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: