Healthcare Provider Details

I. General information

NPI: 1639606734
Provider Name (Legal Business Name): RAKHMAN ESHOV CSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2017
Last Update Date: 06/16/2022
Certification Date: 06/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1585 SOUTHERN OAKS CV
LAWRENCEVILLE GA
30043-3050
US

IV. Provider business mailing address

PO BOX 2550
ROWLETT TX
75030-2550
US

V. Phone/Fax

Practice location:
  • Phone: 214-227-2457
  • Fax: 214-764-0880
Mailing address:
  • Phone: 214-227-2457
  • Fax: 214-764-0880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number4724
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: