Healthcare Provider Details

I. General information

NPI: 1134382153
Provider Name (Legal Business Name): PRIYATHAMA VELLANKI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 05/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 JESSE HILL JR DR SE
ATLANTA GA
30303-3031
US

IV. Provider business mailing address

49 JESSE HILL JR DR SE FOB, RM 498
ATLANTA GA
30303-3049
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-1687
  • Fax:
Mailing address:
  • Phone: 404-778-1687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036123379
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number036123379
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: