Basic Information
| Provider Information | |||||||||
| NPI: | 1639146087 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUTANDI | ||||||||
| FirstName: | REZA | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 116156 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303686156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783125525 | ||||||||
| FaxNumber: | 7703392120 | ||||||||
| Practice Location | |||||||||
| Address1: | 1942 ATKINSON RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300435004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6787750600 | ||||||||
| FaxNumber: | 6783775284 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2006 | ||||||||
| LastUpdateDate: | 02/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 35077882 | OH | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 2193666 | 05 | OH | MEDICAID |