Healthcare Provider Details

I. General information

NPI: 1043224199
Provider Name (Legal Business Name): MARK VAKKUR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 CENTURY PKWY NE SUITE 200
ATLANTA GA
30345-3154
US

IV. Provider business mailing address

1751 VICKERS CIR
DECATUR GA
30030-1033
US

V. Phone/Fax

Practice location:
  • Phone: 404-486-7450
  • Fax: 404-325-3663
Mailing address:
  • Phone: 404-486-7450
  • Fax: 404-325-3663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number47548
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: