MEDICARE: DR. KAVITHA TELLAKULA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	061762	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1952577850
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KAVITHA TELLAKULA MD

Provider Business Mailing Address
First Line	:	3400A OLD MILTON PARKWAY
Second Line	:	SUITE 130
City	:	ALPHARETTA
State	:	GA
Zip	:	30005-4438
Country	:	US
Telephone Number	:	770-664-8898
Fax Number	:	770-772-4377

Provider Business Practice Location Address
First Line	:	3400 OLD MILTON PKWY STE A130
Second Line	:
City	:	ALPHARETTA
State	:	GA
Zip	:	30005-4417
Country	:	US
Telephone Number	:	770-664-8898
Fax Number	:	770-772-4377

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2008
Last Update Date	:	10/12/2020

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