Provider Demographics
NPI:1992800742
Name:CHONGULIA, TERRY SUPANEE (MD)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:SUPANEE
Last Name:CHONGULIA
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 1:2370 HILLSIDE TRCE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-5880
Mailing Address - Country:US
Mailing Address - Phone:770-267-0085
Mailing Address - Fax:
Practice Address - Street 1:513 GREAT OAKS DR STE A
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-8211
Practice Address - Country:US
Practice Address - Phone:770-267-8368
Practice Address - Fax:770-207-0640
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053640173000000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA443409802BMedicaid
GA52872342OtherBC/BS
16BBFCNMedicare PIN
GA443409802BMedicaid