Healthcare Provider Details

I. General information

NPI: 1750592242
Provider Name (Legal Business Name): SIVA PRASAD MULLANGI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 04/03/2024
Certification Date: 04/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 NORTHCREST DR
SPRINGFIELD TN
37172-3973
US

IV. Provider business mailing address

417 NORTHCREST DR
SPRINGFIELD TN
37172-3973
US

V. Phone/Fax

Practice location:
  • Phone: 615-384-8211
  • Fax: 615-384-5859
Mailing address:
  • Phone: 615-384-8211
  • Fax: 615-384-5859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number69619
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: