1548670946 NPI number — MS. NISHITHA REDDY THUMALLAPALLY MD

Table of content: MS. NISHITHA REDDY THUMALLAPALLY MD (NPI 1548670946)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548670946 NPI number — MS. NISHITHA REDDY THUMALLAPALLY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THUMALLAPALLY
Provider First Name:
NISHITHA
Provider Middle Name:
REDDY
Provider Name Prefix Text:
MS.
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:
1548670946
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
12/09/2014
NPI Reactivation Date:
09/23/2015

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7015 A C SKINNER PKWY STE 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32256-6932
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-363-2113
Provider Business Mailing Address Fax Number:
904-363-2606

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
121 WHITEHALL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST AUGUSTINE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32086-5266
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-825-4500
Provider Business Practice Location Address Fax Number:
907-825-3672
Provider Enumeration Date:
05/07/2014

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:  ME159539 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 118147900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6UOLE . This is a "FL BLUE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: QU962 . This is a "MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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