=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609940303
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AJITABH PANDEY M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2006
-----------------------------------------------------
Last Update Date | 02/02/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1670 CLAIRMONT RD VAMC - ATLANTA (MENTAL HEALTH SERVICE
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30033-4004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-321-6111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 515 N DOOLIN DR
-----------------------------------------------------
City | ROSWELL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30076-5130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-649-1800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 25MA08174700
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 060955
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------