Provider Demographics
NPI:1205835501
Name:SRINIVASAN, MUTHAYYAH (MD)
Entity Type:Individual
Prefix:DR
First Name:MUTHAYYAH
Middle Name:
Last Name:SRINIVASAN
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 1:5447 DIVIDEND DR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-8412
Mailing Address - Country:US
Mailing Address - Phone:770-322-8881
Mailing Address - Fax:770-322-8886
Practice Address - Street 1:5447 DIVIDEND DR
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-8412
Practice Address - Country:US
Practice Address - Phone:770-322-8881
Practice Address - Fax:770-322-8886
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052836207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000782788909BMedicaid
GA000782788909BMedicaid