Basic Information
| Provider Information | |||||||||
| NPI: | 1225047301 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHANTHA | ||||||||
| FirstName: | ANAND | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1930 BRANNAN RD | ||||||||
| Address2: | |||||||||
| City: | MCDONOUGH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302534310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782844040 | ||||||||
| FaxNumber: | 6782844076 | ||||||||
| Practice Location | |||||||||
| Address1: | 119 N PARK TRL | ||||||||
| Address2: | |||||||||
| City: | STOCKBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302817373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703893739 | ||||||||
| FaxNumber: | 7703896565 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2006 | ||||||||
| LastUpdateDate: | 01/17/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 050677 | GA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 340020189 | 01 | GA | RAILROAD MEDICARE | OTHER | 000972804A | 05 | GA | MEDICAID | BS6703309 | 01 | GA | DEA | OTHER |