Provider Demographics
NPI:1730173733
Name:REBALA, SRILAKSHMI (MD)
Entity type:Individual
Prefix:DR
First Name:SRILAKSHMI
Middle Name:
Last Name:REBALA
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:PO BOX 7335
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30604-7335
Mailing Address - Country:US
Mailing Address - Phone:706-546-7484
Mailing Address - Fax:706-546-7488
Practice Address - Street 1:1500 OGLETHORPE AVE
Practice Address - Street 2:SUITE 500C
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2179
Practice Address - Country:US
Practice Address - Phone:706-546-7484
Practice Address - Fax:706-546-7488
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-06
Last Update Date:2012-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051081207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA261448399AMedicaid
GA39BDCJMMedicare ID - Type UnspecifiedMEDICARE
GA261448399AMedicaid