Provider Demographics
NPI:1063613503
Name:VINJAMURI, MRIDULA (MD)
Entity type:Individual
Prefix:
First Name:MRIDULA
Middle Name:
Last Name:VINJAMURI
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:PO BOX 12938
Mailing Address - Street 2:C/O CLINIC MANAGEMENT
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30703
Mailing Address - Country:US
Mailing Address - Phone:706-602-7800
Mailing Address - Fax:
Practice Address - Street 1:187 CHASTAIN RD NE
Practice Address - Street 2:SUITE 250
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144
Practice Address - Country:US
Practice Address - Phone:770-218-6450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA87101207RH0003X
NE24264207RH0003X
KY42167207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1063613503OtherRAILROAD MEDICARE
KY3691833000OtherPASSPORT ADVANTAGE
KY7100062420Medicaid
9262087OtherAETNA
1063613503OtherTRICARE
1063613503OtherHUMANA
611277847OtherUNITED HEALTHCARE
KY87086OtherCOVENTRYCARES OF KENTUCKY
000000575213OtherANTHEM BC/BS
C24053OtherCUMBERLAND HEALTHCARE
1063613503OtherHUMANA
KY0510215Medicare PIN