Healthcare Provider Details

I. General information

NPI: 1912402488
Provider Name (Legal Business Name): KISHORE VEDALA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2018
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2174 N DRUID HILLS RD NE
ATLANTA GA
30329-3102
US

IV. Provider business mailing address

3333 BURNET AVE # MLC5018
CINCINNATI OH
45229-3026
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-8218
  • Fax: 404-785-4750
Mailing address:
  • Phone: 513-636-4315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number100716
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: