Provider Demographics
NPI:1366500050
Name:INDIRA DEVU PC
Entity Type:Organization
Organization Name:INDIRA DEVU PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:INDIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-955-1814
Mailing Address - Street 1:2520 WINDY HILL RD SE STE 306
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-8653
Mailing Address - Country:US
Mailing Address - Phone:770-955-1814
Mailing Address - Fax:770-955-2279
Practice Address - Street 1:2520 WINDY HILL RD SE STE 306
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8653
Practice Address - Country:US
Practice Address - Phone:770-955-1814
Practice Address - Fax:770-955-2279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052129174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA279474230BMedicaid
GA279474230BMedicaid
GA11SCDTGMedicare ID - Type UnspecifiedMEDICARE