Provider Demographics
NPI:1518072198
Name:GHANTA, KALYANI SUKHAVASI (MD)
Entity Type:Individual
Prefix:
First Name:KALYANI
Middle Name:SUKHAVASI
Last Name:GHANTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 COMMERCE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2627
Mailing Address - Country:US
Mailing Address - Phone:404-417-5200
Mailing Address - Fax:404-417-5204
Practice Address - Street 1:755 COMMERCE DR STE 200
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2627
Practice Address - Country:US
Practice Address - Phone:404-417-5200
Practice Address - Fax:404-417-5204
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054677207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11SCDXRMedicare ID - Type Unspecified
GAI28724Medicare UPIN