1316255847 NPI number — PRIYANKA SULTANIA DUDANI MD

Table of content: PRIYANKA SULTANIA DUDANI MD (NPI 1316255847)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316255847 NPI number — PRIYANKA SULTANIA DUDANI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SULTANIA DUDANI
Provider First Name:
PRIYANKA
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:
SULTANIA
Provider Other First Name:
PRIYANKA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1316255847
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/23/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
965 RIDGE LAKE BLVD., SUITE 103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38120-9401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-227-4068
Provider Business Mailing Address Fax Number:
901-227-8591

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3722 HARLEM AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVERSIDE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60546-2312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-783-6566
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/17/2010

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: 207R00000X , with the licence number:  125056088 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 49615 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: 49615 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 036.130615 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1316255847 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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