Provider Demographics
NPI:1417914201
Name:KULANGARA, RAJU J (MD)
Entity Type:Individual
Prefix:
First Name:RAJU
Middle Name:J
Last Name:KULANGARA
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 1:6084 PROFESSIONAL PARKWAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134
Mailing Address - Country:US
Mailing Address - Phone:770-920-0085
Mailing Address - Fax:770-920-0062
Practice Address - Street 1:6084 PROFESSIONAL PARKWAY
Practice Address - Street 2:SUITE A
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134
Practice Address - Country:US
Practice Address - Phone:770-920-0085
Practice Address - Fax:770-920-0062
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA022431208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
E95450Medicare UPIN