Healthcare Provider Details

I. General information

NPI: 1760712889
Provider Name (Legal Business Name): SUMAN ANNAMBHOTLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2010
Last Update Date: 05/13/2021
Certification Date: 05/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 JESSE JEWELL PKWY SE
GAINESVILLE GA
30501-3834
US

IV. Provider business mailing address

PO BOX 658
GAINESVILLE GA
30503-0658
US

V. Phone/Fax

Practice location:
  • Phone: 678-207-4000
  • Fax: 770-531-2435
Mailing address:
  • Phone: 770-718-1122
  • Fax: 770-533-4786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberM8500
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number070035
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: