Provider Demographics
NPI:1891738118
Name:RAJEEV, ANGAMPALLY G (MD)
Entity Type:Individual
Prefix:
First Name:ANGAMPALLY
Middle Name:G
Last Name:RAJEEV
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 1:1551 DOCTORS DRIVE
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4139
Mailing Address - Country:US
Mailing Address - Phone:706-884-2641
Mailing Address - Fax:706-884-2353
Practice Address - Street 1:1551 DOCTORS DRIVE
Practice Address - Street 2:BLDG 200
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4139
Practice Address - Country:US
Practice Address - Phone:706-884-2641
Practice Address - Fax:706-884-2353
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057240207RC0000X, 207RI0011X
KS04-32029207RI0011X
GA57240207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSH45812Medicare UPIN