Basic Information
| Provider Information | |||||||||
| NPI: | 1356664007 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PAUL | ||||||||
| FirstName: | PANCHAJANYA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 889128 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303561128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042943835 | ||||||||
| FaxNumber: | 4045087795 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 WISTERIA DR | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305013827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702195407 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2010 | ||||||||
| LastUpdateDate: | 01/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 069419 | GA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 1679063580 | 01 | ARP MANAGEMENT NPI | OTHER | 1730730839 | 01 | SOUTHERN LIVE OAK NPI | OTHER |