Provider Demographics
NPI:1023221199
Name:MUDVARI, SACHIN S (MD)
Entity Type:Individual
Prefix:
First Name:SACHIN
Middle Name:S
Last Name:MUDVARI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4414 LAKE BOONE TRL
Mailing Address - Street 2:SUITE 302
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-7513
Mailing Address - Country:US
Mailing Address - Phone:919-782-8038
Mailing Address - Fax:919-782-8189
Practice Address - Street 1:4414 LAKE BOONE TRL
Practice Address - Street 2:SUITE 302
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7513
Practice Address - Country:US
Practice Address - Phone:919-782-8038
Practice Address - Fax:919-782-8189
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036117885207W00000X
NC200900397207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00416350OtherRRMC
IL036117885Medicaid
IL036117885Medicaid
ILK41245Medicare PIN