Provider Demographics
NPI:1497129399
Name:IMMANENI, SUPRIYA (MD)
Entity Type:Individual
Prefix:
First Name:SUPRIYA
Middle Name:
Last Name:IMMANENI
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 1:308 COLISEUM DR
Mailing Address - Street 2:ST 200
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31217-3865
Mailing Address - Country:US
Mailing Address - Phone:478-742-2180
Mailing Address - Fax:
Practice Address - Street 1:308 COLISEUM DR
Practice Address - Street 2:ST 200
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-3865
Practice Address - Country:US
Practice Address - Phone:478-742-2180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-17
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA95284207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology