Healthcare Provider Details

I. General information

NPI: 1316200710
Provider Name (Legal Business Name): ALOK SUDHAKAR EZHUTHACHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2012
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 JOHNSON FERRY RD
ATLANTA GA
30342-1606
US

IV. Provider business mailing address

1888 POINTE PLACE AVE
ATLANTA GA
30338-7990
US

V. Phone/Fax

Practice location:
  • Phone: 404-851-8000
  • Fax:
Mailing address:
  • Phone: 248-462-2662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301100459
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number212976
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number92500
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: