Provider Demographics
NPI:1699779199
Name:SANDWICH, JAMES THOMAS (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:THOMAS
Last Name:SANDWICH
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 1:450 LANIER AVE W
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-1502
Mailing Address - Country:US
Mailing Address - Phone:770-460-8988
Mailing Address - Fax:770-460-0727
Practice Address - Street 1:450 LANIER AVE W
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1502
Practice Address - Country:US
Practice Address - Phone:770-460-8988
Practice Address - Fax:770-460-0727
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036609174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF54519Medicare UPIN