Healthcare Provider Details

I. General information

NPI: 1124382536
Provider Name (Legal Business Name): SUDHEER TANGELLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2012
Last Update Date: 06/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

878 LAKELAND DR
JACKSON MS
39216-4644
US

IV. Provider business mailing address

PO BOX 4999
JACKSON MS
39296-4999
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-6800
  • Fax: 601-984-6811
Mailing address:
  • Phone: 601-984-5426
  • Fax: 601-984-6889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number836-L
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: