Healthcare Provider Details

I. General information

NPI: 1548670946
Provider Name (Legal Business Name): NISHITHA REDDY THUMALLAPALLY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2014
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date: 12/09/2014
Reactivation Date: 09/23/2015

III. Provider practice location address

121 WHITEHALL DR
ST AUGUSTINE FL
32086-5266
US

IV. Provider business mailing address

7015 A C SKINNER PKWY STE 1
JACKSONVILLE FL
32256-6932
US

V. Phone/Fax

Practice location:
  • Phone: 904-825-4500
  • Fax: 907-825-3672
Mailing address:
  • Phone: 904-363-2113
  • Fax: 904-363-2606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberME159539
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: