Provider Demographics
NPI:1285916148
Name:MARRI, VIJAYA D L PRADEEPTHI (MD,)
Entity type:Individual
Prefix:DR
First Name:VIJAYA
Middle Name:D L PRADEEPTHI
Last Name:MARRI
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:PO BOX 751069
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:521 MOYE BLVD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-2849
Practice Address - Country:US
Practice Address - Phone:252-744-3229
Practice Address - Fax:252-744-3924
Is Sole Proprietor?:No
Enumeration Date:2011-09-15
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125060446207R00000X
NC2015-01672207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1285916148Medicaid
NC19D22OtherBCBS NC
NCNCP833AMedicare PIN