Healthcare Provider Details

I. General information

NPI: 1891135018
Provider Name (Legal Business Name): SRAVAN DHULIPALA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2013
Last Update Date: 07/07/2020
Certification Date: 07/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 REGENCY PARK DR
MCDONOUGH GA
30253-6649
US

IV. Provider business mailing address

105 REGENCY PARK DR
MCDONOUGH GA
30253-6649
US

V. Phone/Fax

Practice location:
  • Phone: 770-506-4119
  • Fax:
Mailing address:
  • Phone: 770-506-4119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number6333
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number83582
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: