Healthcare Provider Details

I. General information

NPI: 1750060513
Provider Name (Legal Business Name): DR. AKSHAY SHARAD BEDMUTHA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2023
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1364 CLIFTON RD NE
ATLANTA GA
30322-6342
US

IV. Provider business mailing address

220 PONCE DE LEON PL UNIT 376
DECATUR GA
30030-3249
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-9729
  • Fax:
Mailing address:
  • Phone: 917-969-1969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number100734
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number100734
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: