Healthcare Provider Details

I. General information

NPI: 1689803959
Provider Name (Legal Business Name): KAVITA REDDY GONE M.B.B.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2009
Last Update Date: 04/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4855 RIVER GREEN PKWY
DULUTH GA
30096-8336
US

IV. Provider business mailing address

1838 AMERICAN WAY
LAWRENCEVILLE GA
30043-6611
US

V. Phone/Fax

Practice location:
  • Phone: 770-622-0880
  • Fax: 770-622-9875
Mailing address:
  • Phone: 770-995-7622
  • Fax: 770-995-7854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number068901
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberL.3041R
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: