Healthcare Provider Details

I. General information

NPI: 1396770806
Provider Name (Legal Business Name): VAJRESHWARI SHIVAPRAKASH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VAJRESHWARI SANNAPPA MD

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 02/09/2022
Certification Date: 02/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 CUMBERLAND PARKWAY
ATLANTA GA
30339
US

IV. Provider business mailing address

3495 PIEDMONT ROAD, NE NINE PIEDMONT CENTER
ATLANTA GA
30305
US

V. Phone/Fax

Practice location:
  • Phone: 404-606-0122
  • Fax:
Mailing address:
  • Phone: 404-364-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number052095
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number052095
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: