Healthcare Provider Details

I. General information

NPI: 1679688220
Provider Name (Legal Business Name): UMPON SANGMALEE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 01/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 C WEST ELM ST
ROCKMART GA
30153-1727
US

IV. Provider business mailing address

826 W ELM ST STE C
ROCKMART GA
30153-1727
US

V. Phone/Fax

Practice location:
  • Phone: 770-684-5348
  • Fax: 770-684-5349
Mailing address:
  • Phone: 770-684-5348
  • Fax: 770-684-5348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberGA17081
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: