Healthcare Provider Details

I. General information

NPI: 1962787705
Provider Name (Legal Business Name): THEJOVATHI EDALA M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2011
Last Update Date: 01/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 W MARKHAM ST SLOT # 783
LITTLE ROCK AR
72205-7101
US

IV. Provider business mailing address

1501 RAHLING RD APT 702
LITTLE ROCK AR
72223-4656
US

V. Phone/Fax

Practice location:
  • Phone: 501-686-8000
  • Fax: 501-526-6562
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberE-9656
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License NumberE-9656
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: