Provider Demographics
NPI:1053518423
Name:DEHGHANY, SIMA (MD)
Entity type:Individual
Prefix:DR
First Name:SIMA
Middle Name:
Last Name:DEHGHANY
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:PO BOX 769609
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-8224
Mailing Address - Country:US
Mailing Address - Phone:770-903-0134
Mailing Address - Fax:770-903-0135
Practice Address - Street 1:1360 UPPER HEMBREE RD STE 100
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-1230
Practice Address - Country:US
Practice Address - Phone:470-956-4430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA062494207QG0300X, 207QH0002X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA347374480GMedicaid
GA347374480HMedicaid
GA1609816123OtherNPI GROUP # GEORGIA CLINIC, PC
GA202I080985Medicare PIN