Provider Demographics
NPI:1124382536
Name:TANGELLA, SUDHEER (MD)
Entity Type:Individual
Prefix:
First Name:SUDHEER
Middle Name:
Last Name:TANGELLA
Suffix:
Gender:M
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:PO BOX 4999
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39296-4999
Mailing Address - Country:US
Mailing Address - Phone:601-984-5426
Mailing Address - Fax:601-984-6889
Practice Address - Street 1:878 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4644
Practice Address - Country:US
Practice Address - Phone:601-984-6800
Practice Address - Fax:601-984-6811
Is Sole Proprietor?:No
Enumeration Date:2012-06-29
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS836-L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine