MEDICARE: SUBODH K LAL MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	052771	GA
2	207RG0100X	Gastroenterology Physician	052771	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699748988
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUBODH K LAL MD

Provider Business Mailing Address
First Line	:	711 CANTON RD NE
Second Line	:	SUITE 300
City	:	MARIETTA
State	:	GA
Zip	:	30060-8948
Country	:	US
Telephone Number	:	678-741-5000
Fax Number	:	678-819-4280

Provider Business Practice Location Address
First Line	:	4441 ATLANTA RD SE STE 204
Second Line	:
City	:	SMYRNA
State	:	GA
Zip	:	30080-6442
Country	:	US
Telephone Number	:	678-741-5000
Fax Number	:	770-739-2318

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/08/2006
Last Update Date	:	08/16/2018

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