=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316388762
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TARAZ SAMANDARI MD PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2013
-----------------------------------------------------
Last Update Date | 07/15/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 CLIFTON RD NE MAILSTOP E-45
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30329-4018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-639-1676
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 412 E PHARR RD
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30030-4426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-704-0976
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number | D0051447
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------