Provider Demographics
NPI:1699741819
Name:LALLY, DAVINDER KAUR (MD)
Entity type:Individual
Prefix:DR
First Name:DAVINDER
Middle Name:KAUR
Last Name:LALLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:DAVINDER
Other - Middle Name:KAUR
Other - Last Name:GURAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:7182 WOODROW ST STE 200
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-2832
Mailing Address - Country:US
Mailing Address - Phone:803-749-1111
Mailing Address - Fax:803-749-0050
Practice Address - Street 1:7182 WOODROW ST STE 200
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063
Practice Address - Country:US
Practice Address - Phone:803-749-1111
Practice Address - Fax:803-749-0050
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13380207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCLL1166Medicaid
SCB918872603Medicare PIN
SCB918877004Medicare PIN
B918877004Medicare ID - Type UnspecifiedRESIDENTS' TEACHING CLINI
B91887Medicare UPIN
SCLL1166Medicaid