Provider Demographics
NPI:1649684887
Name:JILLELLA, DINESH VINAYAK (MD)
Entity type:Individual
Prefix:MR
First Name:DINESH
Middle Name:VINAYAK
Last Name:JILLELLA
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 1:1 UNIVERSITY OF NEW MEXICO
Mailing Address - Street 2:INTERNAL MEDICINE, MSC 10 - 5550
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87131
Mailing Address - Country:US
Mailing Address - Phone:505-272-4661
Mailing Address - Fax:
Practice Address - Street 1:1 UNIVERSITY OF NEW MEXICO
Practice Address - Street 2:INTERNAL MEDICINE, MSC 10 - 5550
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131
Practice Address - Country:US
Practice Address - Phone:505-272-4661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-16
Last Update Date:2019-08-05
Deactivation Date:2015-01-20
Deactivation Code:
Reactivation Date:2015-04-08
Provider Licenses
StateLicense IDTaxonomies
NMRS2014-0273390200000X
GA825322084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program