Provider Demographics
NPI:1306978929
Name:MATTAM, JYOTHI N (MD)
Entity type:Individual
Prefix:DR
First Name:JYOTHI
Middle Name:N
Last Name:MATTAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JYOTHI
Other - Middle Name:N
Other - Last Name:DHUPAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:7902 AMAWALK CIR
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30097-1920
Mailing Address - Country:US
Mailing Address - Phone:770-225-3000
Mailing Address - Fax:770-225-3001
Practice Address - Street 1:3582 OLD MILTON PKWY
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-4465
Practice Address - Country:US
Practice Address - Phone:770-225-3000
Practice Address - Fax:770-225-3001
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0506572084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA26BDJXQMedicare ID - Type Unspecified
GAH91417Medicare UPIN