Provider Demographics
NPI:1396794145
Name:NERELLA, DAMODHAR (MD)
Entity type:Individual
Prefix:
First Name:DAMODHAR
Middle Name:
Last Name:NERELLA
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 1:819 N FANT ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-5717
Mailing Address - Country:US
Mailing Address - Phone:864-261-1800
Mailing Address - Fax:864-261-1856
Practice Address - Street 1:819 N FANT ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-5717
Practice Address - Country:US
Practice Address - Phone:864-261-1800
Practice Address - Fax:864-261-1856
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27041207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC270414Medicaid
SCP00855848OtherRR MEDICARE EFF 10-10
097697620AOtherGEORGIA MEDICAID
SCP00156020OtherRR MEDICARE
SC270414Medicaid
AA05600281Medicare PIN
1153Medicare PIN