Provider Demographics
NPI:1003919069
Name:VISHWANATH, MADHU (MD)
Entity Type:Individual
Prefix:
First Name:MADHU
Middle Name:
Last Name:VISHWANATH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3969 SOUTH COBB DRIVE SE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080
Mailing Address - Country:US
Mailing Address - Phone:770-438-9723
Mailing Address - Fax:770-431-9733
Practice Address - Street 1:3969 SOUTH COBB DRIVE SE
Practice Address - Street 2:SUITE 205
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080
Practice Address - Country:US
Practice Address - Phone:770-438-9723
Practice Address - Fax:770-431-9733
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA056499207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA821760291CMedicaid
GA11SCHTTMedicare PIN
GAI49336Medicare UPIN
GA821760291CMedicaid