Provider Demographics
NPI:1760658447
Name:PETCHETTI, MANJULA RANI (MD)
Entity Type:Individual
Prefix:
First Name:MANJULA
Middle Name:RANI
Last Name:PETCHETTI
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 1:105 YADKIN ST
Mailing Address - Street 2:
Mailing Address - City:ALBEMARLE
Mailing Address - State:NC
Mailing Address - Zip Code:28001-3449
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 YADKIN ST
Practice Address - Street 2:SUITE 303
Practice Address - City:ALBEMARLE
Practice Address - State:NC
Practice Address - Zip Code:28001-3449
Practice Address - Country:US
Practice Address - Phone:980-323-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-02
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME140645208000000X
NC2008-00313208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1760658447Medicaid
NCNCR582BMedicare PIN