1073514352 NPI number — DR. SMITHA GOLLAMUDI M.D.

Table of content: DR. SMITHA GOLLAMUDI M.D. (NPI 1073514352)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073514352 NPI number — DR. SMITHA GOLLAMUDI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOLLAMUDI
Provider First Name:
SMITHA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1073514352
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2864 JOHNSON FERRY RD
Provider Second Line Business Mailing Address:
SUITE 150
Provider Business Mailing Address City Name:
MARIETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30062-5635
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-693-2622
Provider Business Mailing Address Fax Number:
770-693-6039

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5255 LOUGHBORO RD NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
DC
Provider Business Practice Location Address Postal Code:
20016-2695
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
202-537-4787
Provider Business Practice Location Address Fax Number:
202-537-4964
Provider Enumeration Date:
08/09/2005

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: 174400000X , with the licence number:  MD35176 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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