Healthcare Provider Details

I. General information

NPI: 1114274586
Provider Name (Legal Business Name): JYOSTNA DEEPIKA PULLA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2012
Last Update Date: 04/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11109 PARKVIEW PLAZA DR
FORT WAYNE IN
46845-1701
US

IV. Provider business mailing address

1313 WINDING RIDGE DR APT 2B
GRAND BLANC MI
48439-7553
US

V. Phone/Fax

Practice location:
  • Phone: 260-266-2020
  • Fax: 260-266-2009
Mailing address:
  • Phone: 484-343-8071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301100546
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301100546
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: