Provider Demographics
NPI:1790516235
Name:MIRIYALA, MAHIDHAR
Entity type:Individual
Prefix:
First Name:MAHIDHAR
Middle Name:
Last Name:MIRIYALA
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 1:1135 KILDAIRE FARM RD STE 200-35
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-7608
Mailing Address - Country:US
Mailing Address - Phone:313-421-8350
Mailing Address - Fax:
Practice Address - Street 1:1135 KILDAIRE FARM RD STE 200-35
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-7608
Practice Address - Country:US
Practice Address - Phone:313-421-8350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-07
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC74683747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant