Healthcare Provider Details

I. General information

NPI: 1285848689
Provider Name (Legal Business Name): PREMILA MALHOTRA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 08/24/2020
Certification Date: 08/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 COLISEUM DR SUITE 120
MACON GA
31217-3865
US

IV. Provider business mailing address

1835 SAVOY DR SUITE 300
ATLANTA GA
30341-1072
US

V. Phone/Fax

Practice location:
  • Phone: 478-745-6130
  • Fax: 478-745-4443
Mailing address:
  • Phone: 478-745-6130
  • Fax: 478-745-4443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number055279
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: