Provider Demographics
NPI:1720450851
Name:ATHULURU, VINDHYA
Entity Type:Individual
Prefix:
First Name:VINDHYA
Middle Name:
Last Name:ATHULURU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:753 CLASSONA VENUE 10 B
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238
Mailing Address - Country:US
Mailing Address - Phone:917-757-6326
Mailing Address - Fax:
Practice Address - Street 1:1200 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720
Practice Address - Country:US
Practice Address - Phone:706-272-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-28
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
NY296784207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program