Healthcare Provider Details

I. General information

NPI: 1760470892
Provider Name (Legal Business Name): SUNDARI RAJU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 09/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 EAST BROAD STREET
LUMPKIN GA
31815
US

IV. Provider business mailing address

PO BOX 158 126 EAST BROAD STREET
LUMPKIN GA
31815
US

V. Phone/Fax

Practice location:
  • Phone: 229-838-0885
  • Fax: 229-838-0887
Mailing address:
  • Phone: 229-838-0885
  • Fax: 229-838-0887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number040199
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1625183
Identifier TypeOTHER
Identifier State
Identifier IssuerFIRST HEALTH
# 2
IdentifierP00174258
Identifier TypeOTHER
Identifier State
Identifier IssuerRAILROAD MEDICARE
# 3
Identifier000680699F
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer
# 4
Identifier1379773
Identifier TypeOTHER
Identifier State
Identifier IssuerCIGNA
# 5
Identifier0101742
Identifier TypeOTHER
Identifier State
Identifier IssuerUNITED HEALTHCARE
# 6
Identifier52596864001
Identifier TypeOTHER
Identifier State
Identifier IssuerBCBS GA
# 7
Identifier450491390RAJ1
Identifier TypeOTHER
Identifier State
Identifier IssuerEVERGREEN
# 8
Identifier60027561
Identifier TypeOTHER
Identifier State
Identifier IssuerBCBS AL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: