Provider Demographics
NPI:1952577850
Name:TELLAKULA, KAVITHA (MD)
Entity Type:Individual
Prefix:DR
First Name:KAVITHA
Middle Name:
Last Name:TELLAKULA
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 1:3400A OLD MILTON PARKWAY
Mailing Address - Street 2:SUITE 130
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-4438
Mailing Address - Country:US
Mailing Address - Phone:770-664-8898
Mailing Address - Fax:770-772-4377
Practice Address - Street 1:3400 OLD MILTON PKWY STE A130
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-4417
Practice Address - Country:US
Practice Address - Phone:770-664-8898
Practice Address - Fax:770-772-4377
Is Sole Proprietor?:No
Enumeration Date:2008-05-01
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA061762207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003149881AMedicaid
GA202I081898Medicare PIN