Healthcare Provider Details

I. General information

NPI: 1104434307
Provider Name (Legal Business Name): CHRISTINE S PEDDAPANGA DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2020
Last Update Date: 11/20/2023
Certification Date: 11/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 HIGHWAY 13 S
MORTON MS
39117-3353
US

IV. Provider business mailing address

PO BOX 5392
MERIDIAN MS
39302-5392
US

V. Phone/Fax

Practice location:
  • Phone: 601-732-8612
  • Fax: 601-732-1957
Mailing address:
  • Phone: 601-703-9407
  • Fax: 601-703-9283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0377R
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: