Provider Demographics
NPI:1942404421
Name:ATHAVALE, SANJAY MANOHAR (MD)
Entity type:Individual
Prefix:MR
First Name:SANJAY
Middle Name:MANOHAR
Last Name:ATHAVALE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:100 DAWSON COMMONS CIRCLE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:DAWSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30534
Mailing Address - Country:US
Mailing Address - Phone:770-217-6224
Mailing Address - Fax:706-216-4830
Practice Address - Street 1:100 DAWSON COMMONS CIRCLE
Practice Address - Street 2:SUITE 140
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534
Practice Address - Country:US
Practice Address - Phone:770-217-6224
Practice Address - Fax:706-216-4830
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA69172207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003131877IMedicaid
GA003131877JMedicaid
GA003131877MMedicaid
GA202I041060Medicare PIN