Provider Demographics
NPI:1093736613
Name:GURUDUTT, VIVEK V (MD)
Entity Type:Individual
Prefix:
First Name:VIVEK
Middle Name:V
Last Name:GURUDUTT
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4150 DEPUTY BILL CANTRELL MEMORIAL DR SUITE 260
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-2721
Mailing Address - Country:US
Mailing Address - Phone:770-292-3045
Mailing Address - Fax:770-292-3046
Practice Address - Street 1:1360 UPPER HEMBREE RD
Practice Address - Street 2:SUITE 201B
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-1171
Practice Address - Country:US
Practice Address - Phone:770-475-3361
Practice Address - Fax:770-664-4431
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2021-04-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA73912207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA246039YEXCOtherMEDICARE PTAN