Healthcare Provider Details

I. General information

NPI: 1144429978
Provider Name (Legal Business Name): SAMANTHA MUPPALLA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 GLYNN ST S
FAYETTEVILLE GA
30214-2050
US

IV. Provider business mailing address

730 GLYNN ST S
FAYETTEVILLE GA
30214-2050
US

V. Phone/Fax

Practice location:
  • Phone: 770-460-3650
  • Fax:
Mailing address:
  • Phone: 770-460-3650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number04-34160
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number111416
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: