Healthcare Provider Details

I. General information

NPI: 1285916148
Provider Name (Legal Business Name): VIJAYA D L PRADEEPTHI MARRI M.D.,
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2011
Last Update Date: 02/20/2024
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 MOYE BLVD
GREENVILLE NC
27834-2849
US

IV. Provider business mailing address

PO BOX 751069
CHARLOTTE NC
28275-1069
US

V. Phone/Fax

Practice location:
  • Phone: 252-744-3229
  • Fax: 252-744-3924
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125060446
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2015-01672
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: