Provider Demographics
NPI:1124040100
Name:BUNYASARANAND, PRICHA (MD)
Entity Type:Individual
Prefix:
First Name:PRICHA
Middle Name:
Last Name:BUNYASARANAND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PRICHA
Other - Middle Name:
Other - Last Name:BUNYA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, PC
Mailing Address - Street 1:656 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4214
Mailing Address - Country:US
Mailing Address - Phone:770-228-2824
Mailing Address - Fax:770-228-0210
Practice Address - Street 1:656 S 8TH ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4214
Practice Address - Country:US
Practice Address - Phone:770-228-2824
Practice Address - Fax:770-228-0210
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA14687174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD29047Medicare UPIN