Healthcare Provider Details

I. General information

NPI: 1386806032
Provider Name (Legal Business Name): SANA MASOOD MAKHDOOM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 03/19/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 DOCTORS DR STE 102
LAGRANGE GA
30240-4132
US

IV. Provider business mailing address

1555 DOCTORS DR STE 102
LAGRANGE GA
30240-4132
US

V. Phone/Fax

Practice location:
  • Phone: 706-803-7890
  • Fax: 770-999-2850
Mailing address:
  • Phone: 706-803-7890
  • Fax: 770-999-2850

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 Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2011-01216
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberC1-0011610
License Number StateDE
# 4
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number81437
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: