Healthcare Provider Details

I. General information

NPI: 1548552011
Provider Name (Legal Business Name): MUTHU DEEPAK VIGNESH BHASKARAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2011
Last Update Date: 09/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 BOULEVARD NE STE 415
ATLANTA GA
30312-4210
US

IV. Provider business mailing address

285 BOULEVARD, NE ST415
ATLANTA GA
30312
US

V. Phone/Fax

Practice location:
  • Phone: 404-265-4400
  • Fax: 404-265-5542
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number73946
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2084A2900X
TaxonomyNeurocritical Care Physician
License Number73946
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: