Provider Demographics
NPI:1043467665
Name:KODUMAGULLA, MRINALINI SUJALA (MD)
Entity type:Individual
Prefix:DR
First Name:MRINALINI
Middle Name:SUJALA
Last Name:KODUMAGULLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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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
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-26
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC200801499207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5910366Medicaid
NC02DWBOtherBCBS OF NC
NC5910366Medicaid