Healthcare Provider Details

I. General information

NPI: 1548295405
Provider Name (Legal Business Name): NIRMALA D AMARAM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 06/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 UVALDA ST
WAYCROSS GA
31501-4551
US

IV. Provider business mailing address

302 UVALDA ST
WAYCROSS GA
31501-4551
US

V. Phone/Fax

Practice location:
  • Phone: 912-285-2519
  • Fax: 912-284-2482
Mailing address:
  • Phone: 912-285-2519
  • Fax: 912-284-2482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number043159
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number043159
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: