Provider Demographics
NPI:1689838526
Name:SANJUAN, CARISSA ANNE (MD)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:ANNE
Last Name:SANJUAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3780 EISENHOWER PKWY
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31206-0800
Mailing Address - Country:US
Mailing Address - Phone:478-633-5500
Mailing Address - Fax:
Practice Address - Street 1:401 MATTHEW ST
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-1635
Practice Address - Country:US
Practice Address - Phone:740-374-7700
Practice Address - Fax:740-374-7701
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003031207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine