Healthcare Provider Details

I. General information

NPI: 1780114975
Provider Name (Legal Business Name): SUSHANTH RAGHU BODA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2017
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3231 HIGHWAY 34 E STE C
NEWNAN GA
30265-6407
US

IV. Provider business mailing address

3231 HIGHWAY 34 E STE C
NEWNAN GA
30265-6407
US

V. Phone/Fax

Practice location:
  • Phone: 678-971-4167
  • Fax:
Mailing address:
  • Phone: 678-971-4167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number271781
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number125071636
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number92204
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number92204
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: