Provider Demographics
NPI:1982869574
Name:JILLELLAMUDI, SURESH (MD)
Entity type:Individual
Prefix:
First Name:SURESH
Middle Name:
Last Name:JILLELLAMUDI
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 1:3001 LYNDHURST AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4007
Mailing Address - Country:US
Mailing Address - Phone:336-765-0383
Mailing Address - Fax:
Practice Address - Street 1:3001 LYNDHURST AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4007
Practice Address - Country:US
Practice Address - Phone:336-765-0383
Practice Address - Fax:336-760-6918
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2020-04806207R00000X, 207RI0200X, 207RC0200X, 207RC0200X
NH16545207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2080858Medicaid