Provider Demographics
NPI:1245461243
Name:MALLESARA SUDHAKAR, SHWETHA
Entity type:Individual
Prefix:
First Name:SHWETHA
Middle Name:
Last Name:MALLESARA SUDHAKAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 MOREHEAD MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-2963
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1025 MOREHEAD MEDICAL DR
Practice Address - Street 2:SUITE 500
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2963
Practice Address - Country:US
Practice Address - Phone:704-446-2320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-07
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-01296207RE0101X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC2614Medicaid
NC1245461243Medicaid
NCNCR217EMedicare PIN
NCNCR217DMedicare PIN
NCNCR217BMedicare UPIN
SCNC2614Medicaid
NC1245461243Medicaid
NCNCR217FMedicare PIN