Provider Demographics
NPI:1053305631
Name:SOUNDARARAJAN, VIDYA (MD)
Entity Type:Individual
Prefix:DR
First Name:VIDYA
Middle Name:
Last Name:SOUNDARARAJAN
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 1:1791 MULKEY RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1124
Mailing Address - Country:US
Mailing Address - Phone:770-732-5400
Mailing Address - Fax:770-944-0327
Practice Address - Street 1:1791 MULKEY RD
Practice Address - Street 2:SUITE 200
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1124
Practice Address - Country:US
Practice Address - Phone:770-732-5400
Practice Address - Fax:770-944-0327
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047949207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00844841AMedicaid
GA58-1397572OtherFEDERAL TAX ID#
GA16BDTBRMedicare ID - Type Unspecified
GAH03828Medicare UPIN