Healthcare Provider Details

I. General information

NPI: 1992800742
Provider Name (Legal Business Name): TERRY SUPANEE CHONGULIA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 02/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

513 GREAT OAKS DR STE A
MONROE GA
30655-8211
US

IV. Provider business mailing address

2370 HILLSIDE TRCE
MONROE GA
30655-5880
US

V. Phone/Fax

Practice location:
  • Phone: 770-267-8368
  • Fax: 770-207-0640
Mailing address:
  • Phone: 770-267-0085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number053640
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number053640
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: