Provider Demographics
NPI:1982651691
Name:VITHALA, MADHURI V (MD)
Entity Type:Individual
Prefix:
First Name:MADHURI
Middle Name:V
Last Name:VITHALA
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 1:215 BRIGHTWATER DR
Mailing Address - Street 2:
Mailing Address - City:LILLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27546-5156
Mailing Address - Country:US
Mailing Address - Phone:910-984-3080
Mailing Address - Fax:910-615-9766
Practice Address - Street 1:215 BRIGHTWATER DR STE 1221
Practice Address - Street 2:
Practice Address - City:LILLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27546-5156
Practice Address - Country:US
Practice Address - Phone:910-984-3080
Practice Address - Fax:910-615-9776
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2010-01415207RH0003X, 207RH0003X
CT043685208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1982651691Medicaid
CTP00393630OtherRAILROAD MEDICARE
CT38014OtherCONTROLLED SUSTANCE REG