Healthcare Provider Details

I. General information

NPI: 1265726384
Provider Name (Legal Business Name): PAVANI KOLAKALAPUDI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2011
Last Update Date: 03/09/2022
Certification Date: 03/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1404 RIVER PL STE 501
BRASELTON GA
30517-5600
US

IV. Provider business mailing address

3970 DEPUTY BILL CANTRELL MEM STE 100
CUMMING GA
30040-3069
US

V. Phone/Fax

Practice location:
  • Phone: 770-534-2020
  • Fax: 770-534-8025
Mailing address:
  • Phone: 678-513-2273
  • Fax: 678-513-8869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number078781
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: