Healthcare Provider Details

I. General information

NPI: 1841381696
Provider Name (Legal Business Name): SANJEEVA H RAO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 05/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

232 W 2ND ST
JACKSON GA
30233-1907
US

IV. Provider business mailing address

232 W 2ND ST
JACKSON GA
30233-1907
US

V. Phone/Fax

Practice location:
  • Phone: 770-775-4334
  • Fax: 770-775-2787
Mailing address:
  • Phone: 770-775-4334
  • Fax: 770-775-2787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number018723GA
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: