Provider Demographics
NPI:1053344051
Name:MIKKILINENI, HYMAVATI (MD)
Entity type:Individual
Prefix:DR
First Name:HYMAVATI
Middle Name:
Last Name:MIKKILINENI
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 1:483 UPPER RIVERDALE RD SW
Mailing Address - Street 2:SUITE B
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2584
Mailing Address - Country:US
Mailing Address - Phone:770-994-0242
Mailing Address - Fax:770-994-4386
Practice Address - Street 1:483 UPPER RIVERDALE RD SW
Practice Address - Street 2:SUITE B
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2584
Practice Address - Country:US
Practice Address - Phone:770-994-0242
Practice Address - Fax:770-994-4386
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA028440207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00329304AMedicaid
GA581692055OtherTAX IDENTIFICATION NUMBER
GAD30252Medicare UPIN