1891993994 NPI number — INDIRA DORIS KONANUR DO

Table of content: INDIRA DORIS KONANUR DO (NPI 1891993994)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891993994 NPI number — INDIRA DORIS KONANUR DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KONANUR
Provider First Name:
INDIRA
Provider Middle Name:
DORIS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

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:
1891993994
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 779
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN FRANCISCO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94104-7001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
415-658-6791
Provider Business Mailing Address Fax Number:
415-520-0904

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28 STATE ST
Provider Second Line Business Practice Location Address:
SUITE 2850
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02109-1775
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-903-5009
Provider Business Practice Location Address Fax Number:
617-903-5009
Provider Enumeration Date:
07/10/2007

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: 207R00000X , with the licence number:  14926 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 243668 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 30228286 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".




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