Provider Demographics
NPI:1295726099
Name:SUDDALA, SATYA (SONIA) R (MD)
Entity type:Individual
Prefix:MRS
First Name:SATYA (SONIA)
Middle Name:R
Last Name:SUDDALA
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 1:311 MONTROSE DR
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-4257
Mailing Address - Country:US
Mailing Address - Phone:770-389-8950
Mailing Address - Fax:770-389-3848
Practice Address - Street 1:135 EAGLES WALK
Practice Address - Street 2:SUITE 200
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7206
Practice Address - Country:US
Practice Address - Phone:770-389-8950
Practice Address - Fax:770-389-3848
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA035148174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00482567IMedicaid
GAB26761Medicare UPIN
GA16BBBRKMedicare ID - Type Unspecified