Healthcare Provider Details

I. General information

NPI: 1164714937
Provider Name (Legal Business Name): LEELA S. MAXA MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2011
Last Update Date: 05/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 PHILIP BLVD
LAWRENCEVILLE GA
30046-8733
US

IV. Provider business mailing address

53 PERIMETER CTR E #500
ATLANTA GA
30346-2294
US

V. Phone/Fax

Practice location:
  • Phone: 770-995-3000
  • Fax: 770-995-1427
Mailing address:
  • Phone: 770-682-2099
  • Fax: 866-281-8389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number037382
License Number StateGA

VIII. Authorized Official

Name: DR. LEELA S MAXA
Title or Position: OWNER/PHYSICIAN
Credential: M.D.
Phone: 770-682-2099