Provider Demographics
NPI:1538110770
Name:SUBHASH S PUJARA MD LLC
Entity Type:Organization
Organization Name:SUBHASH S PUJARA MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER SOLO INCORPORATE
Authorized Official - Prefix:
Authorized Official - First Name:SUBHASH
Authorized Official - Middle Name:S
Authorized Official - Last Name:PUJARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-985-8802
Mailing Address - Street 1:PO BOX 2917
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31776-2917
Mailing Address - Country:US
Mailing Address - Phone:229-985-8802
Mailing Address - Fax:229-891-2016
Practice Address - Street 1:610 SPARTA RD
Practice Address - Street 2:
Practice Address - City:SANDERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31082-1860
Practice Address - Country:US
Practice Address - Phone:229-985-8802
Practice Address - Fax:229-891-2016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7741Medicare ID - Type UnspecifiedMEDICARE GROUP #