Healthcare Provider Details

I. General information

NPI: 1154378735
Provider Name (Legal Business Name): SUBBA R GOLLAMUDI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 07/25/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 RIDGE LAKE BLVD
MEMPHIS TN
38120-9411
US

IV. Provider business mailing address

PO BOX 22510
JACKSON MS
39225-2510
US

V. Phone/Fax

Practice location:
  • Phone: 901-685-2200
  • Fax: 901-820-2342
Mailing address:
  • Phone: 901-685-2200
  • Fax: 901-255-5631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberE-3527
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number16734
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD0000021892
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: