Provider Demographics
NPI:1477612661
Name:RAJANALA, SUSMITA (MD)
Entity Type:Individual
Prefix:
First Name:SUSMITA
Middle Name:
Last Name:RAJANALA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 PROFESSIONAL DR
Mailing Address - Street 2:SUITE 350
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-3367
Mailing Address - Country:US
Mailing Address - Phone:770-995-0630
Mailing Address - Fax:770-995-1555
Practice Address - Street 1:631 PROFESSIONAL DR
Practice Address - Street 2:SUITE 350
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3367
Practice Address - Country:US
Practice Address - Phone:770-995-0630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA067309207RS0012X, 207RC0200X, 207RP1001X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003121924BMedicaid
GA2021811913Medicare NSC