Provider Demographics
NPI:1841231347
Name:RASALAM, LIVINGSTONE AJIT (MD)
Entity Type:Individual
Prefix:
First Name:LIVINGSTONE
Middle Name:AJIT
Last Name:RASALAM
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 1:303 WOODROW WILSON DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2537
Mailing Address - Country:US
Mailing Address - Phone:229-244-5000
Mailing Address - Fax:229-244-0808
Practice Address - Street 1:303 WOODROW WILSON DR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2537
Practice Address - Country:US
Practice Address - Phone:229-244-5000
Practice Address - Fax:229-244-0808
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033437174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00475208CMedicaid
GAD13871Medicare UPIN
GAGRP3364Medicare ID - Type Unspecified