Provider Demographics
NPI:1043416654
Name:MYNENI, MAMATA
Entity Type:Individual
Prefix:
First Name:MAMATA
Middle Name:
Last Name:MYNENI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5213 S ALSTON AVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-4430
Mailing Address - Country:US
Mailing Address - Phone:919-620-8111
Mailing Address - Fax:
Practice Address - Street 1:2100 ERWIN RD
Practice Address - Street 2:BANNER GOOD SAMARITAN MEDICAL CENTER
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-3941
Practice Address - Country:US
Practice Address - Phone:919-684-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1305152085R0202X
FLME1253362085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology