Healthcare Provider Details

I. General information

NPI: 1538152855
Provider Name (Legal Business Name): UMAMAHESWARI JONNALAGADDA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 02/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

906 BRYAN ST W
DOUGLAS GA
31533-2330
US

IV. Provider business mailing address

906 BRYAN ST W
DOUGLAS GA
31533-2330
US

V. Phone/Fax

Practice location:
  • Phone: 912-383-9300
  • Fax: 912-383-9292
Mailing address:
  • Phone: 912-383-9300
  • Fax: 912-383-9292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number042299
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: