1265494561 NPI number — DR. VENKATESH R. KANDALLU M.D.

Table of content: (NPI 1750309555)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265494561 NPI number — DR. VENKATESH R. KANDALLU M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KANDALLU
Provider First Name:
VENKATESH
Provider Middle Name:
R.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265494561
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/26/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
202 N DIVISION ST
Provider Second Line Business Mailing Address:
STE 201
Provider Business Mailing Address City Name:
AUBURN
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98001-4939
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-939-1230
Provider Business Mailing Address Fax Number:
253-735-1211

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 10TH ST NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUBURN
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98002-4019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-939-1230
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  MD00035482 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0280779 . This is a "STATE L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0280798 . This is a "STATE L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0280788 . This is a "STATE L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8214868 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com