1093736613 NPI number — VIVEK V. GURUDUTT MD

Table of content: (NPI 1740173582)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093736613 NPI number — VIVEK V. GURUDUTT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GURUDUTT
Provider First Name:
VIVEK
Provider Middle Name:
V.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093736613
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/06/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4150 DEPUTY BILL CANTRELL MEMORIAL DR SUITE 260
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CUMMING
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30040-2721
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-292-3045
Provider Business Mailing Address Fax Number:
770-292-3046

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1360 UPPER HEMBREE RD
Provider Second Line Business Practice Location Address:
SUITE 201B
Provider Business Practice Location Address City Name:
ROSWELL
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30076-1171
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-475-3361
Provider Business Practice Location Address Fax Number:
770-664-4431
Provider Enumeration Date:
07/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X , with the licence number:  73912 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 246039YEXC . This is a "MEDICARE PTAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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