Provider Demographics
NPI:1154378735
Name:GOLLAMUDI, SUBBA R (MD)
Entity type:Individual
Prefix:
First Name:SUBBA
Middle Name:R
Last Name:GOLLAMUDI
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 22510
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-2510
Mailing Address - Country:US
Mailing Address - Phone:901-685-2200
Mailing Address - Fax:901-255-5631
Practice Address - Street 1:825 RIDGE LAKE BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-9411
Practice Address - Country:US
Practice Address - Phone:901-685-2200
Practice Address - Fax:901-820-2342
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-3527207W00000X
MS16734207W00000X
TNMD0000021892207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR121686001Medicaid
TN3067983Medicaid
MS00119845Medicaid
TN180018881OtherPALMETTO RR MEDICARE
MS180042504OtherPALMETTO RR MEDICARE
MS00119845Medicaid
MS180000237Medicare PIN
TN180018881OtherPALMETTO RR MEDICARE