Provider Demographics
NPI:1104049519
Name:WESTSIDE PEDIATRICS, P.C.
Entity type:Organization
Organization Name:WESTSIDE PEDIATRICS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAJU
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:KULANGARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-920-0085
Mailing Address - Street 1:6084 PROFESSIONAL PKWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-5613
Mailing Address - Country:US
Mailing Address - Phone:770-920-0085
Mailing Address - Fax:770-920-0062
Practice Address - Street 1:6084 PROFESSIONAL PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-5613
Practice Address - Country:US
Practice Address - Phone:770-920-0085
Practice Address - Fax:770-920-0062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty