Provider Demographics
NPI:1740264035
Name:TAMANNA, SADEKA (MD)
Entity type:Individual
Prefix:
First Name:SADEKA
Middle Name:
Last Name:TAMANNA
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 1:1500 E WOODROW WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-5116
Mailing Address - Country:US
Mailing Address - Phone:601-362-4471
Mailing Address - Fax:
Practice Address - Street 1:1500 E WOODROW WILSON AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5116
Practice Address - Country:US
Practice Address - Phone:601-362-4471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46125207R00000X
MS20279207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FMHP39742OtherHEALTH PARTNERS
MN04-06054OtherMEDICA
MN131014Medicaid
IA565333Medicaid
MS06325569Medicaid
MN155L1TAOtherBCBS
MN1907895OtherARAZ
MN155L1TAOtherBLUE PLUS
MN8586OtherAVERA
MN916487100Medicaid
MN155L1TAOtherBCBS/MEDICARE SUPPLEMENT
MNMH9041035331OtherPPO
MNMH9041035331OtherPPO
MS302I113579Medicare PIN
FMHP39742OtherHEALTH PARTNERS
H88591Medicare UPIN
MS06325569Medicaid