Provider Demographics
NPI:1164818969
Name:KETHA, BAVANA (MD)
Entity Type:Individual
Prefix:DR
First Name:BAVANA
Middle Name:
Last Name:KETHA
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 1:5910 HILLANDALE DR STE 203
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-1878
Mailing Address - Country:US
Mailing Address - Phone:404-778-3712
Mailing Address - Fax:
Practice Address - Street 1:5910 HILLANDALE DR STE 203
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-1878
Practice Address - Country:US
Practice Address - Phone:404-778-3712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-09
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101275402208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program