Basic Information
| Provider Information | |||||||||
| NPI: | 1003009358 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KODUMURI | ||||||||
| FirstName: | VAMSI | ||||||||
| MiddleName: | KIRAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3803 SPRING ST STE 410 | ||||||||
| Address2: | |||||||||
| City: | MOUNT PLEASANT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 534051660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626878260 | ||||||||
| FaxNumber: | 2626878729 | ||||||||
| Practice Location | |||||||||
| Address1: | 3803 SPRING ST STE 410 | ||||||||
| Address2: | |||||||||
| City: | MOUNT PLEASANT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 534051660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626878260 | ||||||||
| FaxNumber: | 2626878729 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2007 | ||||||||
| LastUpdateDate: | 01/25/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 125050331 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0011X | 70364 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
No ID Information.