Provider Demographics
NPI:1972599363
Name:CARLSON, NITI BHALLA (MD)
Entity Type:Individual
Prefix:DR
First Name:NITI
Middle Name:BHALLA
Last Name:CARLSON
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 1:3829 HONORS WAY
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-9147
Mailing Address - Country:US
Mailing Address - Phone:706-855-5929
Mailing Address - Fax:
Practice Address - Street 1:465 N BELAIR RD STE 2E
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3190
Practice Address - Country:US
Practice Address - Phone:706-855-5510
Practice Address - Fax:706-855-7254
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045052207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG45052OtherMEDICAID
GA00914955BMedicaid
H47616Medicare UPIN
SCG45052OtherMEDICAID