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General NPI Number Information
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NPI Number | 1720219397
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Entity Type | Individual
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Provider Name | PENCHALA SWAMY MITTADODLA MD
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Gender | Male
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Dates
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Enumeration Date | 07/30/2009
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Last Update Date | 08/10/2015
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Provider Practice Location Address
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Address Line | 2708 S RIFE MEDICAL LN STE 200
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City | ROGERS
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State | AR
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Zip | 72758-1452
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Country | US
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Telephone | 479-338-3080
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Fax | 479-338-3089
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Provider Business Mailing Address
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Address Line | 2708 S RIFE MEDICAL LN STE 200
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City | ROGERS
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State | AR
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Zip | 72758-1452
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Country | US
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Telephone | 479-338-3080
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Fax | 479-338-3089
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RP1001X
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Taxonomy Name | Pulmonary Disease Physician
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License Number | E-8192
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License Number State | AR
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Taxonomy #2
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Taxonomy Code | 207RC0200X
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Taxonomy Name | Critical Care Medicine (Internal Medicine) Physician
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License Number | E-8192
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License Number State | AR
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