Provider Demographics
NPI:1659334829
Name:KOGANTI, DEVENDRA R (MD)
Entity Type:Individual
Prefix:DR
First Name:DEVENDRA
Middle Name:R
Last Name:KOGANTI
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 1:6507 PROFESSIONAL PL
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-4941
Mailing Address - Country:US
Mailing Address - Phone:770-991-2100
Mailing Address - Fax:770-991-1385
Practice Address - Street 1:6507 PROFESSIONAL PL
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-4941
Practice Address - Country:US
Practice Address - Phone:770-991-2100
Practice Address - Fax:770-991-1385
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2017-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030121207R00000X, 207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00409912AMedicaid
GA00409912BMedicaid
B24053Medicare UPIN
GAB24053Medicare UPIN
GA00409912BMedicaid