Provider Demographics
NPI:1558355685
Name:PATIL, DHARMARAJ HALLIGOUDA (MD)
Entity Type:Individual
Prefix:DR
First Name:DHARMARAJ
Middle Name:HALLIGOUDA
Last Name:PATIL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:11379 SOUTHBRIDGE PKWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-4469
Mailing Address - Country:US
Mailing Address - Phone:770-777-0750
Mailing Address - Fax:770-777-0521
Practice Address - Street 1:11379 SOUTHBRIDGE PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-4469
Practice Address - Country:US
Practice Address - Phone:770-777-0750
Practice Address - Fax:770-777-0521
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-05
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA042386207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00744191FMedicaid
GA00744191FMedicaid
GA11BDPXBMedicare ID - Type Unspecified