Provider Demographics
NPI:1366491235
Name:DEGANIAN, JAVAD (MD)
Entity Type:Individual
Prefix:
First Name:JAVAD
Middle Name:
Last Name:DEGANIAN
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 1:1700 TREE LANE RD
Mailing Address - Street 2:STE 110
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078
Mailing Address - Country:US
Mailing Address - Phone:770-972-0860
Mailing Address - Fax:770-972-0850
Practice Address - Street 1:1700 TREE LANE RD
Practice Address - Street 2:STE 110
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078
Practice Address - Country:US
Practice Address - Phone:770-972-0860
Practice Address - Fax:770-972-0850
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA016053208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics