Provider Demographics
NPI:1144631557
Name:FADIA, MITHILA
Entity type:Individual
Prefix:
First Name:MITHILA
Middle Name:
Last Name:FADIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10208 CERNY ST STE 104
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27617-7885
Mailing Address - Country:US
Mailing Address - Phone:984-500-3165
Mailing Address - Fax:
Practice Address - Street 1:10208 CERNY ST STE 104
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27617-7885
Practice Address - Country:US
Practice Address - Phone:984-500-3165
Practice Address - Fax:984-500-3166
Is Sole Proprietor?:No
Enumeration Date:2014-05-20
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2021-031252084N0008X, 2084N0400X
IL036.1507132084N0008X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0008XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeuromuscular Medicine