Provider Demographics
NPI:1265699920
Name:JAMMALAMADAKA, DIVAKAR (MD)
Entity type:Individual
Prefix:DR
First Name:DIVAKAR
Middle Name:
Last Name:JAMMALAMADAKA
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 1:2386 CLOWER ST STE C105
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-6107
Mailing Address - Country:US
Mailing Address - Phone:678-344-0334
Mailing Address - Fax:
Practice Address - Street 1:2386 CLOWER ST STE C105
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-6107
Practice Address - Country:US
Practice Address - Phone:678-344-0334
Practice Address - Fax:678-344-0343
Is Sole Proprietor?:No
Enumeration Date:2008-05-20
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA66378207RN0300X, 207R00000X, 208M00000X
CT49126208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003118431AMedicaid
GA202I119941Medicare PIN