MEDICARE: DR. UMADEVI MUTHYALA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208M00000X	Hospitalist Physician	2006024366	MO
2	207RE0101X	Endocrinology, Diabetes & Metabolism Physician	0101251547	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C09633	OTHER	VA	GROUP PTAN

General Provider Information

NPI Number	:	1023044765
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. UMADEVI MUTHYALA MD

Provider Business Mailing Address
First Line	:	3660 BOULEVARD
Second Line	:	SUITE G
City	:	COLONIAL HEIGHTS
State	:	VA
Zip	:	23834-1345
Country	:	US
Telephone Number	:	804-526-5566
Fax Number	:	804-526-5568

Provider Business Practice Location Address
First Line	:	3660 BOULEVARD
Second Line	:	SUITE G
City	:	COLONIAL HEIGHTS
State	:	VA
Zip	:	23834-1345
Country	:	US
Telephone Number	:	804-526-5566
Fax Number	:	804-526-5568

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2006
Last Update Date	:	07/05/2012

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