Healthcare Provider Details

I. General information

NPI: 1730387697
Provider Name (Legal Business Name): GIRIDHAR VENKATA VEDULA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 03/15/2022
Certification Date: 03/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1968 PEACHTREE RD NW BLDG 775TH
ATLANTA GA
30309-1281
US

IV. Provider business mailing address

1968 PEACHTREE RD NW BLDG 5TH
ATLANTA GA
30309-1281
US

V. Phone/Fax

Practice location:
  • Phone: 404-605-4600
  • Fax: 404-367-4447
Mailing address:
  • Phone: 404-605-4600
  • Fax: 404-367-4447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License NumberME110289
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License NumberDR.0062058
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME110289
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number90758
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: