Provider Demographics
NPI:1972693299
Name:VISWANADHAM, MADHURI (MD)
Entity Type:Individual
Prefix:DR
First Name:MADHURI
Middle Name:
Last Name:VISWANADHAM
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 1:11125 JONES BRIDGE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-0001
Mailing Address - Country:US
Mailing Address - Phone:770-615-7000
Mailing Address - Fax:770-884-4170
Practice Address - Street 1:11125 JONES BRIDGE RD STE 100
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-0001
Practice Address - Country:US
Practice Address - Phone:770-615-7000
Practice Address - Fax:770-884-4170
Is Sole Proprietor?:No
Enumeration Date:2006-10-15
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM3418208000000X
GA060103208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA527153030EMedicaid