Provider Demographics
NPI:1457565541
Name:DEKALBCOMMUNITYSERVICEBOARD
Entity type:Organization
Organization Name:DEKALBCOMMUNITYSERVICEBOARD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF PSYCHIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DODDAMETIKUR
Authorized Official - Middle Name:S
Authorized Official - Last Name:SIDDAPPA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-243-9500
Mailing Address - Street 1:1662 KANAWHA DR
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-2116
Mailing Address - Country:US
Mailing Address - Phone:404-243-9500
Mailing Address - Fax:404-244-2224
Practice Address - Street 1:1662 KANAWHA DR
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-2116
Practice Address - Country:US
Practice Address - Phone:404-243-9500
Practice Address - Fax:404-244-2224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA021810302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA26BDHWMedicare ID - Type Unspecified