Individual
SUPRIYA IMMANENI
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
308 COLISEUM DR, ST 200, MACON, GA 31217-3865
(478) 742-2180
Mailing address
308 COLISEUM DR, ST 200, MACON, GA 31217-3865
(478) 742-2180
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
95284
GA
207ND0101X
MOHS-Micrographic Surgery Physician
Primary
95284
GA
Other
Enumeration date
11/17/2015
Last updated
01/13/2026
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