Provider Demographics
NPI:1104036524
Name:VALLABHANENI, GEETHA D (MD)
Entity Type:Individual
Prefix:
First Name:GEETHA
Middle Name:D
Last Name:VALLABHANENI
Suffix:
Gender:F
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 MEDICAL PARK DR
Practice Address - Street 2:STE 110
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2948
Practice Address - Country:US
Practice Address - Phone:704-403-1370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2014-02235207RH0003X, 207RX0202X, 207RH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1104036524Medicaid
SCQ02235Medicaid
SCQ02235Medicaid