Healthcare Provider Details

I. General information

NPI: 1427468784
Provider Name (Legal Business Name): KUMARASWAMY GUTTALU KRISHNAMURTHY RAO MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2014
Last Update Date: 02/13/2024
Certification Date: 02/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 WAKE FOREST RD
RALEIGH NC
27609-7317
US

IV. Provider business mailing address

3705 CANCION ST
GREENVILLE NC
27858-6061
US

V. Phone/Fax

Practice location:
  • Phone: 919-954-3000
  • Fax:
Mailing address:
  • Phone: 330-990-0265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number2019-00205
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number2019-00205
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number36284
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: