Provider Demographics
NPI:1083775670
Name:KEOMAHATHAI, SACKDINANH NOK (MD)
Entity type:Individual
Prefix:
First Name:SACKDINANH
Middle Name:NOK
Last Name:KEOMAHATHAI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 HENDERSON DR STE 409
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-3758
Mailing Address - Country:US
Mailing Address - Phone:470-274-2800
Mailing Address - Fax:800-501-3088
Practice Address - Street 1:650 HENDERSON DR STE 409
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-3758
Practice Address - Country:US
Practice Address - Phone:470-274-2800
Practice Address - Fax:800-501-3088
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051054208100000X, 2081P2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000937153AMedicaid
GA000937153AMedicaid
GA25BBFSRMedicare ID - Type Unspecified