Provider Demographics
NPI:1063707354
Name:PASULA, SMITHA REDDY (MD)
Entity type:Individual
Prefix:DR
First Name:SMITHA
Middle Name:REDDY
Last Name:PASULA
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 1:104 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-4542
Mailing Address - Country:US
Mailing Address - Phone:201-658-2864
Mailing Address - Fax:
Practice Address - Street 1:930 W WILSON AVE
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8811
Practice Address - Country:US
Practice Address - Phone:704-663-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-14
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201101319207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNC1587AMedicare PIN