Healthcare Provider Details

I. General information

NPI: 1316058399
Provider Name (Legal Business Name): AYYAGARI INDIRADEVI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6911 PARKWOOD DR
OLIVE BRANCH MS
38654-2111
US

IV. Provider business mailing address

PO BOX 341065
MEMPHIS TN
38184-1065
US

V. Phone/Fax

Practice location:
  • Phone: 901-461-1162
  • Fax:
Mailing address:
  • Phone: 901-385-2342
  • Fax: 901-382-0140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberAI11119
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: