Provider Demographics
NPI:1447463609
Name:MAHADEVAN, CHALAM (MD)
Entity type:Individual
Prefix:
First Name:CHALAM
Middle Name:
Last Name:MAHADEVAN
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 1:4060 JOHNS CREEK PKWY
Mailing Address - Street 2:BLD E
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-1230
Mailing Address - Country:US
Mailing Address - Phone:678-615-3511
Mailing Address - Fax:678-395-4642
Practice Address - Street 1:4060 JOHNS CREEK PKWY
Practice Address - Street 2:BLD E
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-1230
Practice Address - Country:US
Practice Address - Phone:678-615-3511
Practice Address - Fax:678-395-4642
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA59827208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511I330001Medicare PIN