Healthcare Provider Details

I. General information

NPI: 1073523247
Provider Name (Legal Business Name): MADHURIMA ADULLA M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 10/13/2020
Certification Date: 10/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 DULUTH HWY STE 401
LAWRENCEVILLE GA
30046-4303
US

IV. Provider business mailing address

665 DULUTH HWY STE 801
LAWRENCEVILLE GA
30046-8709
US

V. Phone/Fax

Practice location:
  • Phone: 678-312-0450
  • Fax: 770-339-2135
Mailing address:
  • Phone: 470-325-0148
  • Fax: 770-339-0485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number45830-020
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number057035
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number57035
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: