Provider Demographics
NPI:1790831972
Name:MARK VAKKUR, M.D., P.C.
Entity Type:Organization
Organization Name:MARK VAKKUR, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:VAKKUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-486-7450
Mailing Address - Street 1:1751 VICKERS CIR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-1033
Mailing Address - Country:US
Mailing Address - Phone:404-486-7450
Mailing Address - Fax:
Practice Address - Street 1:2200 CENTURY PKWY NE
Practice Address - Street 2:SUITE 200
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-3154
Practice Address - Country:US
Practice Address - Phone:404-486-7450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-28
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA475482084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH42188Medicare UPIN
GA26BDHQJMedicare Oscar/Certification