Healthcare Provider Details

I. General information

NPI: 1568738649
Provider Name (Legal Business Name): SANDEEP PALAKODETI M.D., M.P.H.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2012
Last Update Date: 09/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1169 JEFFERSON AVE
MEMPHIS TN
38104-7217
US

IV. Provider business mailing address

12900 PARK PLAZA DR STE 150
CERRITOS CA
90703-9329
US

V. Phone/Fax

Practice location:
  • Phone: 901-425-1880
  • Fax:
Mailing address:
  • Phone: 562-977-4674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number54853
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: