MEDICARE: DR. MRINALINI SUJALA KODUMAGULLA M.D.

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	207Q00000X	Family Medicine Physician	200801499	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	02DWB	OTHER	NC	BCBS OF NC

General Provider Information

NPI Number	:	1043467665
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MRINALINI SUJALA KODUMAGULLA M.D.

Provider Business Mailing Address
First Line	:	1831 LAKE PINE DR STE 200
Second Line	:
City	:	CARY
State	:	NC
Zip	:	27511-6050
Country	:	US
Telephone Number	:	919-380-1849
Fax Number	:	919-380-1851

Provider Business Practice Location Address
First Line	:	1831 LAKE PINE DR STE 200
Second Line	:
City	:	CARY
State	:	NC
Zip	:	27511-6050
Country	:	US
Telephone Number	:	919-380-1849
Fax Number	:	919-380-1851

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

Provider Enumeration Date	:	08/26/2008
Last Update Date	:	09/30/2019

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