Provider Demographics
NPI:1144251398
Name:BATHULA, SAILATHA (MD)
Entity type:Individual
Prefix:
First Name:SAILATHA
Middle Name:
Last Name:BATHULA
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 1:1867 REMOUNT RD
Mailing Address - Street 2:STE D
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-7401
Mailing Address - Country:US
Mailing Address - Phone:704-854-8799
Mailing Address - Fax:704-854-8803
Practice Address - Street 1:1867 REMOUNT RD
Practice Address - Street 2:STE D
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-7401
Practice Address - Country:US
Practice Address - Phone:704-854-8799
Practice Address - Fax:704-854-8803
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005-01725207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC141HROtherBCBS NC
7178754OtherAETNA
NC5902486Medicaid
5534173OtherCIGNA
P00277681Medicare PIN
7178754OtherAETNA
NCI46530Medicare UPIN