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1497129399 NPI number — SUPRIYA IMMANENI MD

NPI Number: 1497129399
Health Care Provider/Practitioner: SUPRIYA IMMANENI MD

Information about “1497129399” NPI (SUPRIYA IMMANENI MD) exists in 1497129399 in HTML format HTML  |  1497129399 in plain Text format TXT  |  1497129399 in PDF (Portable Document Format) PDF  |  1497129399 in an XML format XML  formats.

NPI Number : 1497129399 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1497129399",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "N",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "IMMANENI",
    "FirstName": "SUPRIYA",
    "MiddleName": null,
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": "MD",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "308 COLISEUM DR",
    "SecondLineMailingAddress": "ST 200",
    "MailingAddressCityName": "MACON",
    "MailingAddressStateName": "GA",
    "MailingAddressPostalCode": "31217-3865",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "478-742-2180",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "308 COLISEUM DR",
    "SecondLinePracticeLocationAddress": "ST 200",
    "PracticeLocationAddressCityName": "MACON",
    "PracticeLocationAddressStateName": "GA",
    "PracticeLocationAddressPostalCode": "31217-3865",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "478-742-2180",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "11/17/2015",
    "LastUpdateDate": "01/02/2024",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "F",
    "Gender": "Female",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "207N00000X",
        "TaxonomyName": "Dermatology Physician",
        "LicenseNumber": "95284",
        "LicenseNumberStateCode": "GA",
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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