Provider Demographics
NPI:1518025741
Name:MIDHA, DEEPAK (MD)
Entity Type:Individual
Prefix:DR
First Name:DEEPAK
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 1:1055 LAKE WINDWARD OVERLOOK
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-9010
Mailing Address - Country:US
Mailing Address - Phone:770-772-9638
Mailing Address - Fax:
Practice Address - Street 1:1055 LAKE WINDWARD OVERLOOK
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-9010
Practice Address - Country:US
Practice Address - Phone:770-772-9638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA058558208600000X
NH11600208600000X
IA19275208600000X
METD061089208600000X
NC208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
C-33074Medicare UPIN