Healthcare Provider Details

I. General information

NPI: 1790214443
Provider Name (Legal Business Name): VENKATADITYA DUGYALA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 STANTONSBURG RD
GREENVILLE NC
27834-2818
US

IV. Provider business mailing address

5325 TOSCANA WAY APT 642
SAN DIEGO CA
92122-5319
US

V. Phone/Fax

Practice location:
  • Phone: 252-847-6172
  • Fax:
Mailing address:
  • Phone: 405-208-2061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A2900X
TaxonomyNeurocritical Care Physician
License Number2023-00249
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: