1871567214 NPI number — DR. BUTCHAIAH KONDRAGUNTA M.D.

Table of content: DR. BUTCHAIAH KONDRAGUNTA M.D. (NPI 1871567214)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871567214 NPI number — DR. BUTCHAIAH KONDRAGUNTA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KONDRAGUNTA
Provider First Name:
BUTCHAIAH
Provider Middle Name:
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:
1871567214
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/22/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
34 MEDICAL PARK BLVD STE G
Provider Second Line Business Mailing Address:
SUITE # G
Provider Business Mailing Address City Name:
PETERSBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23805-9283
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-722-3100
Provider Business Mailing Address Fax Number:
804-722-3120

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
34 MEDICAL PARK BLVD STE G
Provider Second Line Business Practice Location Address:
SUITE # G
Provider Business Practice Location Address City Name:
PETERSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23805-9283
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-722-3100
Provider Business Practice Location Address Fax Number:
804-722-3120
Provider Enumeration Date:
02/14/2006

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: 207RH0003X , with the licence number:  0101223780 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 005847141 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 337600 . This is a "BCBS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 541989200 . This is a "MAILHANDLERS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 005839777 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1316020399 . This is a "HEMATOLOGY/ONCOLOGY" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 258076 . This is a "BCBS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 7608086 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 26641 . This is a "CIGNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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