Provider Demographics
NPI:1396843629
Name:RAJAMANNAR, DOLLY S (OD)
Entity Type:Individual
Prefix:
First Name:DOLLY
Middle Name:S
Last Name:RAJAMANNAR
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:DOLLY
Other - Middle Name:S
Other - Last Name:RAJAMANNAR-KAKARALA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:158 FAIRVIEW RD STE B
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-2795
Mailing Address - Country:US
Mailing Address - Phone:678-289-5835
Mailing Address - Fax:678-289-5837
Practice Address - Street 1:158 FAIRVIEW RD STE B
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-2795
Practice Address - Country:US
Practice Address - Phone:678-289-5835
Practice Address - Fax:678-289-5837
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001823152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00879018BMedicaid
GA00879018AMedicaid
GA00879018AMedicaid
GA00879018BMedicaid