Healthcare Provider Details

I. General information

NPI: 1720070501
Provider Name (Legal Business Name): SUVRAT JAGANNIVAS BHARGAVE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 03/30/2012
Certification Date:
Deactivation Date: 03/23/2006
Reactivation Date: 03/28/2006

III. Provider practice location address

120 HANDLEY RD SUITE 310
TYRONE GA
30290-2177
US

IV. Provider business mailing address

120 HANDLEY RD SUITE 310
TYRONE GA
30290-2177
US

V. Phone/Fax

Practice location:
  • Phone: 770-486-1011
  • Fax: 770-486-1067
Mailing address:
  • Phone: 770-486-1011
  • Fax: 770-486-1067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number047297
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: