Provider Demographics
NPI:1346204062
Name:SERRAO, SANJAY (MD)
Entity Type:Individual
Prefix:
First Name:SANJAY
Middle Name:
Last Name:SERRAO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 J L WHITE DR
Mailing Address - Street 2:STE 150
Mailing Address - City:JASPER
Mailing Address - State:GA
Mailing Address - Zip Code:30143-4893
Mailing Address - Country:US
Mailing Address - Phone:706-299-2200
Mailing Address - Fax:
Practice Address - Street 1:220 J L WHITE DR
Practice Address - Street 2:STE 150
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143-4893
Practice Address - Country:US
Practice Address - Phone:706-299-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94738207R00000X
GA48016207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL41027OtherBCBS
H23403Medicare UPIN
FLU7685ZMedicare ID - Type Unspecified
FL275089900Medicaid