Healthcare Provider Details

I. General information

NPI: 1871116277
Provider Name (Legal Business Name): SEBASTIAN ANDRES GANDARILLAS FRAGA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2020
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 NORTH PARK TRAIL SUITE 300
STOCKBRIDGE GA
30281
US

IV. Provider business mailing address

105 NORTH PARK TRAIL SUITE 300
STOCKBRIDGE GA
30281
US

V. Phone/Fax

Practice location:
  • Phone: 678-284-0800
  • Fax: 678-284-9299
Mailing address:
  • Phone: 678-284-0800
  • Fax: 678-284-9299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number11479
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: