Provider Demographics
NPI:1831402817
Name:DHANEKULA, NISCHALA (MD)
Entity type:Individual
Prefix:
First Name:NISCHALA
Middle Name:
Last Name:DHANEKULA
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 1:3850 WINDERMERE PKWY STE 105
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-7033
Mailing Address - Country:US
Mailing Address - Phone:678-455-2800
Mailing Address - Fax:770-888-9998
Practice Address - Street 1:3850 WINDERMERE PKWY STE 105
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-7033
Practice Address - Country:US
Practice Address - Phone:678-455-2800
Practice Address - Fax:770-888-9998
Is Sole Proprietor?:No
Enumeration Date:2010-07-20
Last Update Date:2024-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37902207R00000X
NY271987207R00000X
GA80279207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC379021Medicaid
NY03757568Medicaid
SCSC6613Medicare PIN