Provider Demographics
NPI:1891143277
Name:MUDIGONDA, TEJASWI VENKATA (MD)
Entity Type:Individual
Prefix:DR
First Name:TEJASWI
Middle Name:VENKATA
Last Name:MUDIGONDA
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 1:1424 W BADDOUR PKWY STE G
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-2685
Mailing Address - Country:US
Mailing Address - Phone:615-314-1699
Mailing Address - Fax:615-622-8905
Practice Address - Street 1:1424 W BADDOUR PKWY STE G
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-2685
Practice Address - Country:US
Practice Address - Phone:615-314-1699
Practice Address - Fax:615-622-8905
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-26
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN68967207ND0900X, 207NS0135X, 207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK207R00000XMedicaid