Provider Demographics
NPI:1801907845
Name:SEBASTIAN, CHIRIYANKANDATH SIMON (MD)
Entity type:Individual
Prefix:
First Name:CHIRIYANKANDATH
Middle Name:SIMON
Last Name:SEBASTIAN
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 1:1499 WALTON WAY
Mailing Address - Street 2:STE 1400
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2602
Mailing Address - Country:US
Mailing Address - Phone:706-828-6410
Mailing Address - Fax:706-722-5187
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:706-721-3141
Practice Address - Fax:706-721-6602
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0318282084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000788895AMedicaid
SCG31828Medicaid
D84446Medicare UPIN
GA26BDGMKMedicare ID - Type UnspecifiedGA MEDICARE