Provider Demographics
NPI:1598847618
Name:INDRAKRISHNAN, BHUVANENDRAM (MD)
Entity Type:Individual
Prefix:DR
First Name:BHUVANENDRAM
Middle Name:
Last Name:INDRAKRISHNAN
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 1:2887 DARLINGTON RUN
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-4315
Mailing Address - Country:US
Mailing Address - Phone:678-377-8252
Mailing Address - Fax:770-963-0122
Practice Address - Street 1:475 PHILIP BLVD
Practice Address - Street 2:SUITE 304
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8737
Practice Address - Country:US
Practice Address - Phone:678-377-8252
Practice Address - Fax:770-963-0122
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042289207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG12056Medicare UPIN