Provider Demographics
NPI:1407964356
Name:KINI, SARVOTHAM (MD)
Entity Type:Individual
Prefix:
First Name:SARVOTHAM
Middle Name:
Last Name:KINI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SAM
Other - Middle Name:
Other - Last Name:KINI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3959 WHITE HORSE LN SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-6408
Mailing Address - Country:US
Mailing Address - Phone:843-412-0072
Mailing Address - Fax:706-713-2222
Practice Address - Street 1:108 SPEAR RD
Practice Address - Street 2:SUITE 309
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30602-0001
Practice Address - Country:US
Practice Address - Phone:706-542-9592
Practice Address - Fax:706-713-2222
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13292207P00000X
GA034170207P00000X, 208D00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC132920Medicaid
GA003100353AMedicaid
B02904Medicare UPIN
SC132920Medicaid