Provider Demographics
NPI:1164947115
Name:MODERN DERMATOLOGY ATLANTA
Entity Type:Organization
Organization Name:MODERN DERMATOLOGY ATLANTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NAGA
Authorized Official - Middle Name:B
Authorized Official - Last Name:MEDURI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-280-2594
Mailing Address - Street 1:5696 WHITEHALL WALK
Mailing Address - Street 2:
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30338-2655
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5696 WHITEHALL WALK
Practice Address - Street 2:
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338
Practice Address - Country:US
Practice Address - Phone:423-280-2594
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-11
Last Update Date:2017-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA57104207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty