Provider Demographics
NPI:1427194257
Name:VISWANATHAN, GAUTHAM (MD)
Entity Type:Individual
Prefix:
First Name:GAUTHAM
Middle Name:
Last Name:VISWANATHAN
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 1:35 COLLIER RD NW
Mailing Address - Street 2:STE 610
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1613
Mailing Address - Country:US
Mailing Address - Phone:404-355-7375
Mailing Address - Fax:404-350-9781
Practice Address - Street 1:35 COLLIER RD NW
Practice Address - Street 2:STE 610
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1613
Practice Address - Country:US
Practice Address - Phone:404-355-7375
Practice Address - Fax:404-350-9781
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059360A207R00000X
GA71645207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA71645OtherMEDICAL LICENSE
IN01059360AOtherMEDICAL LICENSE
IN01059360AOtherMEDICAL LICENSE