Healthcare Provider Details

I. General information

NPI: 1386819381
Provider Name (Legal Business Name): KOHILAVANI VELAYUDAM M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2008
Last Update Date: 02/27/2023
Certification Date: 02/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 DULUTH PARK LN STE 600
DULUTH GA
30096-3243
US

IV. Provider business mailing address

3500 DULUTH PARK LN STE 600
DULUTH GA
30096-3243
US

V. Phone/Fax

Practice location:
  • Phone: 470-799-1640
  • Fax: 877-807-0753
Mailing address:
  • Phone: 470-799-1640
  • Fax: 877-807-0753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number57.010619
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number72584
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number72584
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License Number72584
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: