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General NPI Number Information
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NPI Number | 1972722791
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Entity Type | Individual
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Provider Name | VIDYA PRADHAN PHOENIX M.D.
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Gender | Female
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Dates
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Enumeration Date | 04/24/2007
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Last Update Date | 09/03/2020
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Provider Practice Location Address
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Address Line | 2700 HIGHWAY 34 EAST BLDG 300
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City | NEWNAN
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State | GA
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Zip | 30265-2315
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Country | US
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Telephone | 678-423-7700
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Fax | 678-423-7710
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Provider Business Mailing Address
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Address Line | 5901A PEACHTREE DUNWOODY RD STE 500
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City | ATLANTA
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State | GA
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Zip | 30328-7162
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Country | US
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Telephone | 678-781-7373
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Fax | 678-538-1972
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 059853
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License Number State | GA
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