Provider Demographics
NPI:1245804285
Name:BALSARA, SANISHA
Entity Type:Individual
Prefix:
First Name:SANISHA
Middle Name:
Last Name:BALSARA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 CORPORATE CENTER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-4129
Mailing Address - Country:US
Mailing Address - Phone:770-968-6464
Mailing Address - Fax:
Practice Address - Street 1:1000 CORPORATE CENTER DR STE 200
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-4129
Practice Address - Country:US
Practice Address - Phone:770-968-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-14
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA13945207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program