Provider Demographics
NPI:1164600623
Name:VALLABHANENI, AKHIL (MD)
Entity Type:Individual
Prefix:
First Name:AKHIL
Middle Name:
Last Name:VALLABHANENI
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 1:460 NORTHSIDE CHEROKEE BLVD STE 130
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-8017
Mailing Address - Country:US
Mailing Address - Phone:678-493-2527
Mailing Address - Fax:678-493-5608
Practice Address - Street 1:460 NORTHSIDE CHEROKEE BLVD STE 130
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-8017
Practice Address - Country:US
Practice Address - Phone:678-493-2527
Practice Address - Fax:678-493-5608
Is Sole Proprietor?:No
Enumeration Date:2008-02-07
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD153603207RP1001X
GA076513207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500633229Medicaid
ORR160857Medicare PIN
OR500633229Medicaid