Provider Demographics
NPI:1295873024
Name:MUTHU, PREM KUMAR (MD)
Entity type:Individual
Prefix:
First Name:PREM
Middle Name:KUMAR
Last Name:MUTHU
Suffix:
Gender:M
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:PO BOX 551
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28687-0551
Mailing Address - Country:US
Mailing Address - Phone:704-878-8884
Mailing Address - Fax:704-878-8883
Practice Address - Street 1:215 B WEST BROAD STREET
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677
Practice Address - Country:US
Practice Address - Phone:704-878-8884
Practice Address - Fax:704-878-8883
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89029JMedicaid
NC2218030BMedicare ID - Type Unspecified
NCG16773Medicare UPIN