Healthcare Provider Details

I. General information

NPI: 1174690630
Provider Name (Legal Business Name): SAILAJA TUMMALA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 05/12/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 COWAN DRIVE
LEBANON MO
65536
US

IV. Provider business mailing address

1622 W CALEB CT
SPRINGFIELD MO
65810-1525
US

V. Phone/Fax

Practice location:
  • Phone: 417-532-2805
  • Fax: 417-532-2865
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2011022971
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: