Provider Demographics
NPI:1952393803
Name:VISHNUBHOTLA, PRIYA SHIVA (MD)
Entity type:Individual
Prefix:
First Name:PRIYA
Middle Name:SHIVA
Last Name:VISHNUBHOTLA
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 1:70 W GORE ST
Mailing Address - Street 2:STE 100
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1124
Mailing Address - Country:US
Mailing Address - Phone:407-426-8484
Mailing Address - Fax:407-426-8575
Practice Address - Street 1:1412 MILSTEAD AVE NE STE 300
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3877
Practice Address - Country:US
Practice Address - Phone:404-918-2320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93654207RH0003X
GA95261207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology