Provider Demographics
NPI:1801818927
Name:MUTHU, AMRUTHAVALLI
Entity Type:Individual
Prefix:
First Name:AMRUTHAVALLI
Middle Name:
Last Name:MUTHU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:284 EXECUTIVE PARK DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-1831
Mailing Address - Country:US
Mailing Address - Phone:704-939-1100
Mailing Address - Fax:
Practice Address - Street 1:2129 STATESVILLE BLVD
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28147-1411
Practice Address - Country:US
Practice Address - Phone:704-633-3616
Practice Address - Fax:704-636-8818
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC97001112084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8911304Medicaid
NCG49530Medicare UPIN
NC8911304Medicaid