Provider Demographics
NPI:1215162466
Name:WAKE FAMILY MEDICINE PC
Entity type:Organization
Organization Name:WAKE FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MRINALINI
Authorized Official - Middle Name:SUJALA
Authorized Official - Last Name:KODUMAGULLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-395-3491
Mailing Address - Street 1:1831 LAKE PINE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-6050
Mailing Address - Country:US
Mailing Address - Phone:919-380-1849
Mailing Address - Fax:919-380-1851
Practice Address - Street 1:1831 LAKE PINE DR STE 200
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-6050
Practice Address - Country:US
Practice Address - Phone:919-380-1849
Practice Address - Fax:919-380-1851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-18
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2023128BMedicare PIN