Healthcare Provider Details

I. General information

NPI: 1205097920
Provider Name (Legal Business Name): LUBAINA M. RANGWALA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 01/13/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 TOWNPARK LN NW KAISER PERMANENTE TOWNPARK MEDICAL CENTER
KENNESAW GA
30144-5579
US

IV. Provider business mailing address

3495 PIEDMONT RD NE NINE PIEDMONT CENTER
ATLANTA GA
30305-1717
US

V. Phone/Fax

Practice location:
  • Phone: 770-794-4016
  • Fax:
Mailing address:
  • Phone: 404-364-7070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number0101250056
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number069161
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: