Basic Information
| Provider Information | |||||||||
| NPI: | 1093268781 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KODUMURI | ||||||||
| FirstName: | NISHANTH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 E MCBEE AVE FL 4 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296012842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645338603 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8 RICHLAND MEDICAL PARK DR STE 420 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292038004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034348050 | ||||||||
| FaxNumber: | 8039333005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2016 | ||||||||
| LastUpdateDate: | 10/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | LL39923 | SC | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 39923 | SC | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.