Provider Demographics
NPI:1285652784
Name:GUNNA, VIJAYASUDHA (MD)
Entity Type:Individual
Prefix:
First Name:VIJAYASUDHA
Middle Name:
Last Name:GUNNA
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 1:11912 JONES BRIDGE RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30005-4613
Mailing Address - Country:US
Mailing Address - Phone:770-754-1600
Mailing Address - Fax:770-754-1605
Practice Address - Street 1:11912 JONES BRIDGE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30005-4613
Practice Address - Country:US
Practice Address - Phone:770-754-1600
Practice Address - Fax:770-754-1605
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA55232207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003112003BMedicaid
GA003112003AMedicaid
GA202I466594Medicare PIN