Provider Demographics
NPI:1083610448
Name:PUJARA, SUBHASH S (MD)
Entity Type:Individual
Prefix:DR
First Name:SUBHASH
Middle Name:S
Last Name:PUJARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1499 WALTON WAY
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2603
Mailing Address - Country:US
Mailing Address - Phone:706-724-6100
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:706-724-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2014-09-18
Deactivation Date:2010-07-02
Deactivation Code:
Reactivation Date:2011-01-07
Provider Licenses
StateLicense IDTaxonomies
GA0326382085N0904X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000971242CMedicaid
GA000971242BMedicaid
GA30BDLCFMedicare ID - Type UnspecifiedMEDICARE
GA000971242CMedicaid