Healthcare Provider Details

I. General information

NPI: 1043203011
Provider Name (Legal Business Name): SUDHAKAR JONNALAGADDA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 05/12/2022
Certification Date: 05/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SHIRLEY AVE
DOUGLAS GA
31533-2332
US

IV. Provider business mailing address

300 SHIRLEY AVE
DOUGLAS GA
31533-2332
US

V. Phone/Fax

Practice location:
  • Phone: 912-384-7275
  • Fax: 912-384-4343
Mailing address:
  • Phone: 912-384-7275
  • Fax: 912-384-4343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number041589
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: