Provider Demographics
NPI:1659523991
Name:VUPADHYAYULA, PHANI MOHAN
Entity Type:Individual
Prefix:
First Name:PHANI MOHAN
Middle Name:
Last Name:VUPADHYAYULA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 BALTUSROL LN
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-9031
Mailing Address - Country:US
Mailing Address - Phone:704-813-7476
Mailing Address - Fax:
Practice Address - Street 1:1795 DR FRANK GASTON BLVD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1190
Practice Address - Country:US
Practice Address - Phone:803-260-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-17
Last Update Date:2024-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2013-01115207R00000X
SC40598207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC1962Medicaid
SC40598OtherSC MEDICAL LICENSE
SCFV2330455OtherDEA