Provider Demographics
NPI:1083613525
Name:RAJEEV, KALYANI (MD)
Entity Type:Individual
Prefix:
First Name:KALYANI
Middle Name:
Last Name:RAJEEV
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KALYANI
Other - Middle Name:
Other - Last Name:ANGAMPALLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:301 MEDICAL DR
Mailing Address - Street 2:SUITE 504
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4144
Mailing Address - Country:US
Mailing Address - Phone:706-882-5437
Mailing Address - Fax:
Practice Address - Street 1:301 MEDICAL DR
Practice Address - Street 2:SUITE 504
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4144
Practice Address - Country:US
Practice Address - Phone:706-882-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002006501208000000X
GA058657208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA416240451HMedicaid