Provider Demographics
NPI:1497745251
Name:MIDHA, RAJU (MD)
Entity Type:Individual
Prefix:
First Name:RAJU
Middle Name:
Last Name:MIDHA
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 1:1404 MONTREAL RD
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084
Mailing Address - Country:US
Mailing Address - Phone:770-492-8665
Mailing Address - Fax:770-492-8663
Practice Address - Street 1:1404 MONTREAL RD
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084
Practice Address - Country:US
Practice Address - Phone:770-492-8665
Practice Address - Fax:770-492-8663
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-24
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA54164207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA054164OtherLICENSE
GA003108944BMedicaid
GAH84398Medicare UPIN