Provider Demographics
NPI:1366456204
Name:MORTHALA, SUDHAKAR REDDY (MD)
Entity Type:Individual
Prefix:DR
First Name:SUDHAKAR
Middle Name:REDDY
Last Name:MORTHALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2171 HIGHWAY 1 S
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:SC
Mailing Address - Zip Code:29045-9051
Mailing Address - Country:US
Mailing Address - Phone:803-438-0455
Mailing Address - Fax:803-438-0457
Practice Address - Street 1:2171 HIGHWAY 1 S
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:SC
Practice Address - Zip Code:29045-9051
Practice Address - Country:US
Practice Address - Phone:803-438-0455
Practice Address - Fax:803-438-0457
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC284782084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC28478OtherMEDICAL LICENSE
SC2028478OtherSC CONTROLLED DRUG PERMIT
SCFM2464179OtherFEDERAL DEA