Provider Demographics
NPI:1053602128
Name:AGNETTA, VLATKA (MD)
Entity type:Individual
Prefix:DR
First Name:VLATKA
Middle Name:
Last Name:AGNETTA
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 1:136 BATTLEFIELD CROSSING CT
Mailing Address - Street 2:
Mailing Address - City:RINGGOLD
Mailing Address - State:GA
Mailing Address - Zip Code:30736-5176
Mailing Address - Country:US
Mailing Address - Phone:706-277-7311
Mailing Address - Fax:706-529-7210
Practice Address - Street 1:2358 LIFESTYLE WAY STE 212
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-4904
Practice Address - Country:US
Practice Address - Phone:423-521-1100
Practice Address - Fax:423-521-1200
Is Sole Proprietor?:No
Enumeration Date:2011-04-25
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA86364207N00000X
CAA122120207N00000X, 207P00000X
FLME140586207N00000X
TN61320207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104355800Medicaid