Healthcare Provider Details

I. General information

NPI: 1649684887
Provider Name (Legal Business Name): DINESH VINAYAK JILLELLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2014
Last Update Date: 08/05/2019
Certification Date:
Deactivation Date: 01/20/2015
Reactivation Date: 04/08/2015

III. Provider practice location address

1 UNIVERSITY OF NEW MEXICO INTERNAL MEDICINE, MSC 10 - 5550
ALBUQUERQUE NM
87131
US

IV. Provider business mailing address

1 UNIVERSITY OF NEW MEXICO INTERNAL MEDICINE, MSC 10 - 5550
ALBUQUERQUE NM
87131
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-4661
  • Fax:
Mailing address:
  • Phone: 505-272-4661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRS2014-0273
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number82532
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: