Healthcare Provider Details

I. General information

NPI: 1912181819
Provider Name (Legal Business Name): VIDYA S YALAMANCHILI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 12/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 CLIFTON RD NE
ATLANTA GA
30322-1060
US

IV. Provider business mailing address

1405 CLIFTON RD NE
ATLANTA GA
30322-1060
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-6670
  • Fax: 404-785-6670
Mailing address:
  • Phone: 404-785-6670
  • Fax: 404-785-6670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number059038
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: