Provider Demographics
NPI:1245731298
Name:DHALIWAL, SANDEEP (MD)
Entity type:Individual
Prefix:DR
First Name:SANDEEP
Middle Name:
Last Name:DHALIWAL
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 1:1685 MARS HILL RD NW STE 201
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-7180
Mailing Address - Country:US
Mailing Address - Phone:770-485-0031
Mailing Address - Fax:678-903-4137
Practice Address - Street 1:1685 MARS HILL RD NW STE 201
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-7180
Practice Address - Country:US
Practice Address - Phone:770-485-0031
Practice Address - Fax:678-903-4137
Is Sole Proprietor?:No
Enumeration Date:2018-02-26
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA87239207Q00000X, 207Q00000X
390200000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA87239OtherMEDICAL LICENSE
1174292882OtherORGANIZATION NPI
GA1245731298OtherNPI PROVIDER