Provider Demographics
NPI:1720134166
Name:TYAGI, SWAYAMPRABHA S (MD)
Entity Type:Individual
Prefix:
First Name:SWAYAMPRABHA
Middle Name:S
Last Name:TYAGI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SWAYAMPRABHA
Other - Middle Name:SUBRAMANIAM
Other - Last Name:IYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:414 LUGENIA DR
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-7210
Mailing Address - Country:US
Mailing Address - Phone:912-537-9355
Mailing Address - Fax:912-537-7038
Practice Address - Street 1:414 LUGENIA DR
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-7210
Practice Address - Country:US
Practice Address - Phone:912-537-9355
Practice Address - Fax:912-537-7038
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA32318208000000X
AZ47063208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000517833FMedicaid
GA000517833HMedicaid
GA000517833BMedicaid
GA000517833IMedicaid