Provider Demographics
NPI:1194958900
Name:MOTHUKURI, ANANTH (MD)
Entity type:Individual
Prefix:DR
First Name:ANANTH
Middle Name:
Last Name:MOTHUKURI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:776 E PROVIDENCE RD APT D111
Mailing Address - Street 2:
Mailing Address - City:ALDAN
Mailing Address - State:PA
Mailing Address - Zip Code:19018-4342
Mailing Address - Country:US
Mailing Address - Phone:217-361-6005
Mailing Address - Fax:
Practice Address - Street 1:2540 WINDY HILL RD SE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8605
Practice Address - Country:US
Practice Address - Phone:470-644-1274
Practice Address - Fax:470-644-1119
Is Sole Proprietor?:No
Enumeration Date:2009-08-26
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY270144207L00000X
GA96863207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology