Healthcare Provider Details

I. General information

NPI: 1093817801
Provider Name (Legal Business Name): SHAILENDER K. PEESAPATI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 01/13/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 OLD NORCROSS RD STE A
LAWRENCEVILLE GA
30046-4311
US

IV. Provider business mailing address

601 OLD NORCROSS RD STE A
LAWRENCEVILLE GA
30046-4311
US

V. Phone/Fax

Practice location:
  • Phone: 770-963-2474
  • Fax: 770-963-2476
Mailing address:
  • Phone: 770-963-2474
  • Fax: 770-963-2476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number055540
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: