Provider Demographics
NPI:1043224199
Name:VAKKUR, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:VAKKUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1751 VICKERS CIR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-1033
Mailing Address - Country:US
Mailing Address - Phone:404-486-7450
Mailing Address - Fax:404-325-3663
Practice Address - Street 1:2200 CENTURY PKWY NE
Practice Address - Street 2:SUITE 200
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-3154
Practice Address - Country:US
Practice Address - Phone:404-486-7450
Practice Address - Fax:404-325-3663
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA475482084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00976302AMedicaid
GA26BDHQJMedicare ID - Type Unspecified
GA00976302AMedicaid