Provider Demographics
NPI:1750592242
Name:MULLANGI, SIVA PRASAD (MD)
Entity type:Individual
Prefix:
First Name:SIVA
Middle Name:PRASAD
Last Name:MULLANGI
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 1:417 NORTHCREST DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:TN
Mailing Address - Zip Code:37172-3973
Mailing Address - Country:US
Mailing Address - Phone:615-384-8211
Mailing Address - Fax:615-384-5859
Practice Address - Street 1:417 NORTHCREST DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:TN
Practice Address - Zip Code:37172-3973
Practice Address - Country:US
Practice Address - Phone:615-384-8211
Practice Address - Fax:615-384-5859
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN69619208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1750592242Medicaid