Healthcare Provider Details

I. General information

NPI: 1194145185
Provider Name (Legal Business Name): SWETHA BODDEDA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2014
Last Update Date: 05/19/2022
Certification Date: 05/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 WESTERN AVE STE 305A
CONWAY AR
72034-4982
US

IV. Provider business mailing address

PO BOX 9662
CONWAY AR
72033-9662
US

V. Phone/Fax

Practice location:
  • Phone: 501-358-6145
  • Fax: 501-504-6642
Mailing address:
  • Phone: 501-852-1363
  • Fax: 501-852-1364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberE12202
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: