Provider Demographics
NPI:1336195254
Name:MUDIYALA, RADHIKA (MD)
Entity Type:Individual
Prefix:DR
First Name:RADHIKA
Middle Name:
Last Name:MUDIYALA
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 1:3606 HIGHLANDS PKWY SE
Mailing Address - Street 2:BLDG # 1
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30082-5184
Mailing Address - Country:US
Mailing Address - Phone:678-303-5082
Mailing Address - Fax:678-303-5160
Practice Address - Street 1:3606 HIGHLANDS PKWY SE
Practice Address - Street 2:BLDG # 1
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082-5184
Practice Address - Country:US
Practice Address - Phone:678-303-5082
Practice Address - Fax:678-303-5160
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051069207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA109113329AMedicaid
GAH76578Medicare UPIN
GAGRP6423Medicare ID - Type Unspecified