Healthcare Provider Details

I. General information

NPI: 1730172016
Provider Name (Legal Business Name): SHANTHALAXMI R IYER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: SHANTHALAXMI N MOOTERI MD

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3579 HIGHWAY 138 STE 103
STOCKBRIDGE GA
30281-4142
US

IV. Provider business mailing address

3579 HIGHWAY 138 STE 103
STOCKBRIDGE GA
30281-4142
US

V. Phone/Fax

Practice location:
  • Phone: 678-565-3300
  • Fax: 678-565-3311
Mailing address:
  • Phone: 678-565-3300
  • Fax: 678-565-3311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number051836
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number051836
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: