Provider Demographics
NPI:1497932685
Name:BASAVARAJU, MADHURI P (MD)
Entity Type:Individual
Prefix:MRS
First Name:MADHURI
Middle Name:P
Last Name:BASAVARAJU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:MADHURI
Other - Middle Name:
Other - Last Name:PUTCHA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3495 PIEDMONT ROAD NE
Mailing Address - Street 2:NINE PIEDMONT CENTER
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305
Mailing Address - Country:US
Mailing Address - Phone:404-364-7070
Mailing Address - Fax:
Practice Address - Street 1:3650 STEVE REYNOLDS BOULEVARD
Practice Address - Street 2:KAISER PERMANENTE GWINNETT MEDICAL OFFICE
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096
Practice Address - Country:US
Practice Address - Phone:770-931-6010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-30
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002102208000000X
GA062947208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics