Healthcare Provider Details

I. General information

NPI: 1528233723
Provider Name (Legal Business Name): LAKSHMAN KUMAR DINAVAHI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2008
Last Update Date: 02/03/2024
Certification Date: 02/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3505 LASSITER FALLS DR NE
MARIETTA GA
30062-4199
US

IV. Provider business mailing address

3505 LASSITER FALLS DR NE
MARIETTA GA
30062-4199
US

V. Phone/Fax

Practice location:
  • Phone: 414-916-9031
  • Fax:
Mailing address:
  • Phone: 414-916-9031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number70088
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number52384-20
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number70088
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number52384-20
License Number StateWI
# 5
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number70088
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: