Provider Demographics
NPI:1801991575
Name:KHARIDI, VISWANATHA (MD)
Entity type:Individual
Prefix:
First Name:VISWANATHA
Middle Name:
Last Name:KHARIDI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KHARIDI
Other - Middle Name:S
Other - Last Name:VISWANATHA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 769609
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-8224
Mailing Address - Country:US
Mailing Address - Phone:770-449-0990
Mailing Address - Fax:770-448-8818
Practice Address - Street 1:6920 JIMMY CARTER BLVD
Practice Address - Street 2:STE. 100
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30071-1277
Practice Address - Country:US
Practice Address - Phone:770-449-0990
Practice Address - Fax:770-448-8818
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK112492084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOE69270Medicare UPIN
GAGRP2768Medicare ID - Type UnspecifiedGA CLINIC GROUP #
GA13BDFDDMedicare ID - Type Unspecified