Provider Demographics
NPI:1821652421
Name:VEGULLA, ATCHYUTA DEEPTHI (MBBS)
Entity Type:Individual
Prefix:
First Name:ATCHYUTA
Middle Name:DEEPTHI
Last Name:VEGULLA
Suffix:
Gender:F
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 RECTOR ST
Mailing Address - Street 2:
Mailing Address - City:MILLBURN
Mailing Address - State:NJ
Mailing Address - Zip Code:07041-1102
Mailing Address - Country:US
Mailing Address - Phone:309-363-8704
Mailing Address - Fax:
Practice Address - Street 1:585 SCHENECTADY AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-1822
Practice Address - Country:US
Practice Address - Phone:718-604-5401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-29
Last Update Date:2023-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
TXU0869207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty