Healthcare Provider Details

I. General information

NPI: 1073804969
Provider Name (Legal Business Name): SRIVIDYA KODURU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SRIVIDYA THULLURU

II. Dates (important events)

Enumeration Date: 04/26/2011
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6325 HOSPITAL PKWY
JOHNS CREEK GA
30097-5775
US

IV. Provider business mailing address

6325 HOSPITAL PKWY
JOHNS CREEK GA
30097-5775
US

V. Phone/Fax

Practice location:
  • Phone: 678-474-7038
  • Fax:
Mailing address:
  • Phone: 678-474-7038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number73185
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number073185
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number73185
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License Number73185
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: