Individual
MD SAON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1000 MEDICAL CENTER BLVD, LAWRENCEVILLE, GA 30046-7694
(678) 312-1000
Mailing address
PO BOX 1746, INDIANAPOLIS, IN 46206-1746
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
4351046892
MI
2085R0202X
Diagnostic Radiology Physician
111198
GA
2085R0204X
Vascular & Interventional Radiology Physician
Primary
111198
GA
208D00000X
General Practice Physician
Primary
43188
AL
Other
Enumeration date
05/20/2020
Last updated
08/13/2026
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