Basic Information
| Provider Information | |||||||||
| NPI: | 1164600623 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VALLABHANENI | ||||||||
| FirstName: | AKHIL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 460 NORTHSIDE CHEROKEE BLVD STE 130 | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301158017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784932527 | ||||||||
| FaxNumber: | 6784935608 | ||||||||
| Practice Location | |||||||||
| Address1: | 460 NORTHSIDE CHEROKEE BLVD STE 130 | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301158017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784932527 | ||||||||
| FaxNumber: | 6784935608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2008 | ||||||||
| LastUpdateDate: | 04/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | MD153603 | OR | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RP1001X | 076513 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 500633229 | 05 | OR | MEDICAID |