Healthcare Provider Details

I. General information

NPI: 1689651770
Provider Name (Legal Business Name): RAVINDRA EDUPUGANTI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 12/18/2019
Certification Date: 12/18/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 WHITCHER ST NE SUITE 350
MARIETTA GA
30060-1155
US

IV. Provider business mailing address

55 WHITCHER ST NE STE 350
MARIETTA GA
30060-1129
US

V. Phone/Fax

Practice location:
  • Phone: 770-424-6893
  • Fax: 678-819-0357
Mailing address:
  • Phone: 770-424-6893
  • Fax: 770-424-9095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number063858
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number063858
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number063858
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: