Provider Demographics
NPI:1164714937
Name:LEELA S. MAXA MD, LLC
Entity Type:Organization
Organization Name:LEELA S. MAXA MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LEELA
Authorized Official - Middle Name:S
Authorized Official - Last Name:MAXA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-682-2099
Mailing Address - Street 1:53 PERIMETER CTR E
Mailing Address - Street 2:#500
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30346-2294
Mailing Address - Country:US
Mailing Address - Phone:770-682-2099
Mailing Address - Fax:866-281-8389
Practice Address - Street 1:311 PHILIP BLVD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8733
Practice Address - Country:US
Practice Address - Phone:770-995-3000
Practice Address - Fax:770-995-1427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-11
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA037382174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF67924Medicare UPIN