Provider Demographics
NPI: | 1952698318 |
---|---|
Name: | SANAPUREDDY, PADMAJA |
Entity Type: | Individual |
Prefix: | |
First Name: | PADMAJA |
Middle Name: | |
Last Name: | SANAPUREDDY |
Suffix: | |
Gender: | F |
Credentials: | |
Other - Prefix: | |
Other - First Name: | NA |
Other - Middle Name: | |
Other - Last Name: | NA |
Other - Suffix: | |
Other - Last Name Type: | Other Name |
Other - Credentials: | MD |
Mailing Address - Street 1: | 2500 N STATE ST |
Mailing Address - Street 2: | |
Mailing Address - City: | JACKSON |
Mailing Address - State: | MS |
Mailing Address - Zip Code: | 39216-4500 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 601-815-4778 |
Mailing Address - Fax: | 601-984-5420 |
Practice Address - Street 1: | 2500 N STATE ST |
Practice Address - Street 2: | FAMILY MEDICINE, SLEEP MEDICINE |
Practice Address - City: | JACKSON |
Practice Address - State: | MS |
Practice Address - Zip Code: | 39216-4500 |
Practice Address - Country: | US |
Practice Address - Phone: | 601-815-4778 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2011-07-06 |
Last Update Date: | 2016-07-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MS | 23686 | 207Q00000X, 207QS1201X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207QS1201X | Allopathic & Osteopathic Physicians | Family Medicine | Sleep Medicine |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MS | 04129381 | Medicaid | |
MS | P01500396 | Other | RR MEDICARE |
MS | 04129381 | Medicaid |