Provider Demographics
NPI:1689835936
Name:PEECHARA, MADHAVI LATHA (MD)
Entity Type:Individual
Prefix:MRS
First Name:MADHAVI
Middle Name:LATHA
Last Name:PEECHARA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:855 GOLD HILL RD
Mailing Address - Street 2:STE 106
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-8075
Mailing Address - Country:US
Mailing Address - Phone:252-451-2700
Mailing Address - Fax:252-451-2702
Practice Address - Street 1:10589 E NC HIGHWAY 97
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27803-9208
Practice Address - Country:US
Practice Address - Phone:252-442-1807
Practice Address - Fax:252-442-1649
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-19
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10032241207Q00000X
NC2011-01382207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5919404Medicaid
NC5919404Medicaid