Provider Demographics
NPI:1336146174
Name:SIRCAR, ROUL R (MD)
Entity Type:Individual
Prefix:DR
First Name:ROUL
Middle Name:R
Last Name:SIRCAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ROUL
Other - Middle Name:
Other - Last Name:SIRCAR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, CCD
Mailing Address - Street 1:4450 CALIBRE XING NW
Mailing Address - Street 2:SUITE 1224
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-4103
Mailing Address - Country:US
Mailing Address - Phone:770-974-6550
Mailing Address - Fax:770-974-6551
Practice Address - Street 1:4450 CALIBRE XING NW
Practice Address - Street 2:SUITE 1224
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-4103
Practice Address - Country:US
Practice Address - Phone:770-974-6550
Practice Address - Fax:770-974-6551
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2010-05-05
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
GA047530207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F27275Medicare UPIN