Provider Demographics
NPI:1073514352
Name:GOLLAMUDI, SMITHA (MD)
Entity Type:Individual
Prefix:DR
First Name:SMITHA
Middle Name:
Last Name:GOLLAMUDI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2864 JOHNSON FERRY RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-5635
Mailing Address - Country:US
Mailing Address - Phone:770-693-2622
Mailing Address - Fax:770-693-6039
Practice Address - Street 1:5255 LOUGHBORO RD NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20016-2695
Practice Address - Country:US
Practice Address - Phone:202-537-4787
Practice Address - Fax:202-537-4964
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD35176174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
G34657Medicare UPIN
DC015906R19Medicare ID - Type Unspecified