Provider Demographics
NPI:1578578340
Name:GUDAPATI, VIJAYA LAKSHMI (MD)
Entity Type:Individual
Prefix:
First Name:VIJAYA
Middle Name:LAKSHMI
Last Name:GUDAPATI
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 1:5410 MARYLAND WAY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5064
Mailing Address - Country:US
Mailing Address - Phone:615-377-5670
Mailing Address - Fax:615-377-1678
Practice Address - Street 1:777 HEMLOCK ST
Practice Address - Street 2:MSC 117
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2102
Practice Address - Country:US
Practice Address - Phone:478-633-7550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051941207R00000X
NJ25MA07481900207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA815814465AMedicaid
GA52212638001OtherBCBS - GA
GAP00355494Medicare PIN
GA815814465AMedicaid
GA11SCGKBMedicare PIN
GA52212638001OtherBCBS - GA