Basic Information
| Provider Information | |||||||||
| NPI: | 1578578340 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUDAPATI | ||||||||
| FirstName: | VIJAYA | ||||||||
| MiddleName: | LAKSHMI | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5410 MARYLAND WAY | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153775670 | ||||||||
| FaxNumber: | 6153771678 | ||||||||
| Practice Location | |||||||||
| Address1: | 777 HEMLOCK ST | ||||||||
| Address2: | MSC 117 | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312012102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4786337550 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 10/22/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 051941 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 25MA07481900 | NJ | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 815814465A | 05 | GA | MEDICAID | 52212638001 | 01 | GA | BCBS - GA | OTHER |