Healthcare Provider Details

I. General information

NPI: 1851366454
Provider Name (Legal Business Name): JAYASHREE VENKATESH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JAYASHREE VENUGOPAL PURUSHOTHAMALU MD

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1435 BROADMOOR BLVD KAISER PERMANENTE SUGAR HILL-BUFORD MEDICAL CENTER
SUGAR HILL GA
30518
US

IV. Provider business mailing address

3495 PIEDMONT ROAD, NE NINE PIEDMONT CENTER
ATLANTA GA
30305
US

V. Phone/Fax

Practice location:
  • Phone: 678-765-5700
  • Fax: 540-636-8920
Mailing address:
  • Phone: 404-504-5678
  • Fax: 540-636-8920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101237911
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number065912
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: