1508801978 NPI number — JYOTHIRMAI KONDAPANENI MD

Table of content: JYOTHIRMAI KONDAPANENI MD (NPI 1508801978)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508801978 NPI number — JYOTHIRMAI KONDAPANENI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KONDAPANENI
Provider First Name:
JYOTHIRMAI
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508801978
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3495 PIEDMONT RD NE
Provider Second Line Business Mailing Address:
NINE PIEDMONT CENTER
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30305-1717
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-364-7000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2400 MOUNT ZION PKWY
Provider Second Line Business Practice Location Address:
KP SOUTHWOOD MEDICAL CENTER
Provider Business Practice Location Address City Name:
JONESBORO
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30236-2500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-603-3572
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/18/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , with the licence number:  058052 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0003X , with the licence number: 58052 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 876548862A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".