Provider Demographics
NPI:1215592704
Name:PRADHAN, MOHAMMAD (CAA)
Entity Type:Individual
Prefix:MR
First Name:MOHAMMAD
Middle Name:
Last Name:PRADHAN
Suffix:
Gender:M
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2199 SUGAR SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-5056
Mailing Address - Country:US
Mailing Address - Phone:678-469-0172
Mailing Address - Fax:
Practice Address - Street 1:5671 PEACHTREE DUNWOODY RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-5000
Practice Address - Country:US
Practice Address - Phone:404-257-8601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPENDING207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA9999Medicaid