Healthcare Provider Details

I. General information

NPI: 1821086554
Provider Name (Legal Business Name): JOSE ANDUJAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 10/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 WHITCHER ST NE SUITE 130
MARIETTA GA
30060-1155
US

IV. Provider business mailing address

55 WHITCHER ST NE SUITE 130
MARIETTA GA
30060-1155
US

V. Phone/Fax

Practice location:
  • Phone: 770-428-0462
  • Fax: 770-427-8001
Mailing address:
  • Phone: 770-428-0462
  • Fax: 770-427-8001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number35084250
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number62463
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: