Provider Demographics
NPI:1124095484
Name:RAJU, MUDUNURI V (MD)
Entity type:Individual
Prefix:DR
First Name:MUDUNURI
Middle Name:V
Last Name:RAJU
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 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6174
Mailing Address - Fax:
Practice Address - Street 1:200 FLEETWOOD DR
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640
Practice Address - Country:US
Practice Address - Phone:864-442-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20898208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1316155112OtherGROUP NPI
SCT48874Medicaid
SC110200011OtherRAILROAD MEDICARE
SC1124095484OtherNPI
SCP00437301OtherRAILROAD MEDICARE
SCGP4690Medicaid
SCP00209467OtherRAILROAD MEDICARE
SCGP4690Medicaid
SCG634043365Medicare PIN
SC1316155112OtherGROUP NPI
SCP00437301OtherRAILROAD MEDICARE
SC1124095484Medicare PIN
SCP00437301Medicare PIN
SCP00209467OtherRAILROAD MEDICARE
SCG634048688Medicare UPIN
SCT48874Medicaid