Provider Demographics
NPI:1992805006
Name:PATRO, NIBEDITA (MD)
Entity type:Individual
Prefix:
First Name:NIBEDITA
Middle Name:
Last Name:PATRO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1080 SANDERS RD
Mailing Address - Street 2:STE 100
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-8057
Mailing Address - Country:US
Mailing Address - Phone:770-887-2323
Mailing Address - Fax:770-887-2325
Practice Address - Street 1:1080 SANDERS RD
Practice Address - Street 2:STE 100
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-8057
Practice Address - Country:US
Practice Address - Phone:770-887-2323
Practice Address - Fax:770-887-2325
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA058092207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA085000920GMedicaid
GA000974509MMedicaid
GA000974509NMedicaid
GA000974509LMedicaid
GA000974509NMedicaid
GA000974509MMedicaid