Basic Information
| Provider Information | |||||||||
| NPI: | 1962787705 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | EDALA | ||||||||
| FirstName: | THEJOVATHI | ||||||||
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| NamePrefix: | DR. | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1501 RAHLING RD APT 702 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722234656 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4301 W MARKHAM ST | ||||||||
| Address2: | SLOT # 783 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722057101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016868000 | ||||||||
| FaxNumber: | 5015266562 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2011 | ||||||||
| LastUpdateDate: | 01/23/2017 | ||||||||
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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 | 207L00000X | E-9656 | AR | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP3000X | E-9656 | AR | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology |
No ID Information.