Healthcare Provider Details

I. General information

NPI: 1851427140
Provider Name (Legal Business Name): SUNIL TERRY PERSAUD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2406 BEMISS RD SUITE C
VALDOSTA GA
31602-1997
US

IV. Provider business mailing address

4060 KILARNEY CIR
VALDOSTA GA
31602-0815
US

V. Phone/Fax

Practice location:
  • Phone: 229-293-9555
  • Fax: 229-293-9557
Mailing address:
  • Phone: 229-293-9555
  • Fax: 229-293-9557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number048175
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberME0061636
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: