Provider Demographics
NPI:1417188103
Name:MAMILLA, PAVAN KUMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:PAVAN KUMAR
Middle Name:
Last Name:MAMILLA
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 1:11379 SOUTHBRIDGE PKWY STE A
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-4402
Mailing Address - Country:US
Mailing Address - Phone:770-777-0750
Mailing Address - Fax:770-777-0521
Practice Address - Street 1:11379 SOUTHBRIDGE PKWY STE A
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-4402
Practice Address - Country:US
Practice Address - Phone:770-777-0750
Practice Address - Fax:770-777-0521
Is Sole Proprietor?:No
Enumeration Date:2009-07-29
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.33421207Q00000X
GA79227207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL103I082339OtherPTAN
AL161689Medicaid
AL511-49721OtherBLUE CROSS