Basic Information
| Provider Information | |||||||||
| NPI: | 1770045015 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUDHI | ||||||||
| FirstName: | SUSHMA | ||||||||
| MiddleName: | |||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 706 DIXIE ST STE 210 | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301173889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708128640 | ||||||||
| FaxNumber: | 7708388650 | ||||||||
| Practice Location | |||||||||
| Address1: | 706 DIXIE ST STE 210 | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301173889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708128640 | ||||||||
| FaxNumber: | 7708388650 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2019 | ||||||||
| LastUpdateDate: | 05/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 91782 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.