Provider Demographics
NPI:1023093887
Name:REKLAITIS, VIDA M (MD)
Entity type:Individual
Prefix:DR
First Name:VIDA
Middle Name:M
Last Name:REKLAITIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:VIDA
Other - Middle Name:R
Other - Last Name:SKANDALAKIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:51 HONOUR AVE NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1119
Mailing Address - Country:US
Mailing Address - Phone:770-856-4147
Mailing Address - Fax:
Practice Address - Street 1:1000 JOHNSON FERRY RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1606
Practice Address - Country:US
Practice Address - Phone:404-851-6936
Practice Address - Fax:404-851-6024
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034718207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000509605BMedicaid
GA10044962OtherAMERIGROUP
GA000509605CMedicaid
GA004823OtherBCBS
GA10480OtherKAISER
GA245538OtherBCBS
GA333414OtherWELLCARE
GA00509605BMedicaid
GA93BDQHGMedicare PIN
GA004823OtherBCBS
GA000509605CMedicaid
GA930109998Medicare PIN