Basic Information
| Provider Information | |||||||||
| NPI: | 1851595367 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUTHIKONDA | ||||||||
| FirstName: | SASIDHAR | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1267 HIGHWAY 54 W | ||||||||
| Address2: | SUITE 2200 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302142114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707160051 | ||||||||
| FaxNumber: | 7707160087 | ||||||||
| Practice Location | |||||||||
| Address1: | 1267 HIGHWAY 54 W | ||||||||
| Address2: | SUITE 2200 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302142114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707160051 | ||||||||
| FaxNumber: | 7707160087 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2007 | ||||||||
| LastUpdateDate: | 05/03/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 057471 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 054496 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 214686737A-M | 05 | GA | MEDICAID |