Provider Demographics
NPI:1073804969
Name:KODURU, SRIVIDYA
Entity Type:Individual
Prefix:
First Name:SRIVIDYA
Middle Name:
Last Name:KODURU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SRIVIDYA
Other - Middle Name:
Other - Last Name:THULLURU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6325 HOSPITAL PKWY
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30097-5775
Mailing Address - Country:US
Mailing Address - Phone:678-474-7038
Mailing Address - Fax:
Practice Address - Street 1:6325 HOSPITAL PKWY
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-5775
Practice Address - Country:US
Practice Address - Phone:678-474-7038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-26
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA073185208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program