Provider Demographics
NPI:1679739981
Name:PUPPALA, SUSMITHA (MD)
Entity type:Individual
Prefix:DR
First Name:SUSMITHA
Middle Name:
Last Name:PUPPALA
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 1:2701 N DECATUR RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-5918
Mailing Address - Country:US
Mailing Address - Phone:404-501-5422
Mailing Address - Fax:404-501-1771
Practice Address - Street 1:2701 N DECATUR RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033
Practice Address - Country:US
Practice Address - Phone:404-501-5422
Practice Address - Fax:404-501-1771
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA069426207R00000X, 208M00000X
IL036120875207R00000X
ALMD.30083207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALIND NPI / 130250Medicaid
AL102I110804Medicare PIN