Provider Demographics
NPI:1639436439
Name:AMITA N DAVE, MD PC
Entity Type:Organization
Organization Name:AMITA N DAVE, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMITA
Authorized Official - Middle Name:N
Authorized Official - Last Name:DAVE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-948-8680
Mailing Address - Street 1:3825 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-6831
Mailing Address - Country:US
Mailing Address - Phone:770-948-8680
Mailing Address - Fax:770-944-1337
Practice Address - Street 1:3825 MEDICAL PARK DR
Practice Address - Street 2:SUITE 100
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-6831
Practice Address - Country:US
Practice Address - Phone:770-948-8680
Practice Address - Fax:770-944-1337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-18
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA023724207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
003116112AOtherMEDICAID PAYEE ID NUMBER
GA000405402DMedicaid
GA=========OtherTID NUMBER
B63496Medicare UPIN
11BDFTMMedicare PIN