Provider Demographics
NPI:1174817316
Name:RONGALA, VENKATA SATYA MUTYA PRAKASH (MD)
Entity Type:Individual
Prefix:
First Name:VENKATA
Middle Name:SATYA MUTYA PRAKASH
Last Name:RONGALA
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 1:777 HEMLOCK ST # 104
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-2102
Mailing Address - Country:US
Mailing Address - Phone:478-633-7550
Mailing Address - Fax:478-633-3235
Practice Address - Street 1:777 HEMLOCK ST # 104
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2102
Practice Address - Country:US
Practice Address - Phone:478-633-7550
Practice Address - Fax:478-633-3235
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-06
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA72105207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine