Basic Information
| Provider Information | |||||||||
| NPI: | 1902907546 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IYYUNNI | ||||||||
| FirstName: | UJWALA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 24535 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336234535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278232188 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8999 US HIGHWAY 19 N | ||||||||
| Address2: | |||||||||
| City: | PINELLAS PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337825811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275769999 | ||||||||
| FaxNumber: | 7275765606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 03/05/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME0074910 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110221946 | 01 | FL | RR MCR LOC 2 | OTHER | 43562 | 01 | FL | BLUE CROSS | OTHER | P00658955 | 01 | FL | RR MCR LOC 1 | OTHER | 253567000 | 05 | FL | MEDICAID |