Basic Information
Provider Information
NPI: 1003002627
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: KADIYALA
FirstName: SAMATHA
MiddleName: KRISHNA
NamePrefix: DR.
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 215 OAK DRIVE SOUTH
Address2: SUITE B
City: LAKE JACKSON
State: TX
PostalCode: 775665617
CountryCode: US
TelephoneNumber: 9792669544
FaxNumber: 9795299737
Practice Location
Address1: 506 THIS WAY ST
Address2:  
City: LAKE JACKSON
State: TX
PostalCode: 775665128
CountryCode: US
TelephoneNumber: 9792669544
FaxNumber: 9795299737
Other Information
ProviderEnumerationDate: 09/18/2007
LastUpdateDate: 06/06/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207V00000XN4502TXY Allopathic & Osteopathic PhysiciansObstetrics & Gynecology 

ID Information
IDTypeStateIssuerDescription
20644200105TX MEDICAID


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