Provider Demographics
NPI:1750318416
Name:KALATHIL, SUMODH C (MD)
Entity type:Individual
Prefix:
First Name:SUMODH
Middle Name:C
Last Name:KALATHIL
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 1:1025 VERDAE BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-4032
Mailing Address - Country:US
Mailing Address - Phone:864-242-4683
Mailing Address - Fax:864-240-8104
Practice Address - Street 1:1025 VERDAE BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-4032
Practice Address - Country:US
Practice Address - Phone:864-242-4683
Practice Address - Fax:864-240-8104
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC30422207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC304227Medicaid
SC571004971034OtherBCBS
SC571004971034OtherBCBS