Provider Demographics
NPI:1407880941
Name:MORTHALA, SUNEETHA (MD)
Entity Type:Individual
Prefix:DR
First Name:SUNEETHA
Middle Name:
Last Name:MORTHALA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SUNEETHA
Other - Middle Name:
Other - Last Name:KOLLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4611 HARD SCRABBLE RD
Mailing Address - Street 2:SUITE 359
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-8584
Mailing Address - Country:US
Mailing Address - Phone:803-462-2824
Mailing Address - Fax:803-386-0283
Practice Address - Street 1:2233 CLEMSON RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-8016
Practice Address - Country:US
Practice Address - Phone:803-462-2824
Practice Address - Fax:803-386-0283
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28893207R00000X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC288931Medicaid
I54694Medicare UPIN
SCAA13852603Medicare ID - Type Unspecified
SC288931Medicaid
SCAA13852603Medicare PIN