Provider Demographics
NPI:1609010800
Name:VINJAMARAM, SANJAY (MD)
Entity Type:Individual
Prefix:
First Name:SANJAY
Middle Name:
Last Name:VINJAMARAM
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 1:1100 JOHNSON FERRY RD STE 510
Mailing Address - Street 2:
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1743
Mailing Address - Country:US
Mailing Address - Phone:404-419-1165
Mailing Address - Fax:404-419-1179
Practice Address - Street 1:1505 NORTHSIDE BLVD STE 4600
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-7658
Practice Address - Country:US
Practice Address - Phone:770-205-5292
Practice Address - Fax:770-205-5291
Is Sole Proprietor?:No
Enumeration Date:2009-05-01
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA84344207RH0003X
TXP43914207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX328711201Medicaid
TX329826YN56Medicare PIN