1518058569 NPI number — DR. LAVANYA KODALI M.D.

Table of content: DR. LAVANYA KODALI M.D. (NPI 1518058569)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518058569 NPI number — DR. LAVANYA KODALI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KODALI
Provider First Name:
LAVANYA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1518058569
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2005
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST SYRACUSE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13057-4505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-449-0513
Provider Business Mailing Address Fax Number:
315-362-5120

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 N JAMES ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROME
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13440-2844
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
153-387-0003
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/27/2006

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: 207L00000X , with the licence number:  231455 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: K142-0001 . This is a "CAREFIRST 2005" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1518058569 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 04193115 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 484645 . This is a "NCPPO" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 9385084 . This is a "PHCS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 033579 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 293961 . This is a "AMERIGROUP" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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