Provider Demographics
NPI:1528047016
Name:MAHATHRE, VIJAY K (MD)
Entity type:Individual
Prefix:
First Name:VIJAY
Middle Name:K
Last Name:MAHATHRE
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:PO BOX 277329
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-7329
Mailing Address - Country:US
Mailing Address - Phone:800-377-8721
Mailing Address - Fax:304-523-2241
Practice Address - Street 1:163 S TALLAHASSEE ST
Practice Address - Street 2:
Practice Address - City:HAZLEHURST
Practice Address - State:GA
Practice Address - Zip Code:31539-6465
Practice Address - Country:US
Practice Address - Phone:912-375-7781
Practice Address - Fax:912-375-4055
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041612207P00000X
GA41612207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52581283022OtherBLUECROSS BLUESHIELD
GA000721201SMedicaid
F25097Medicare UPIN