Basic Information
Provider Information | |||||||||
NPI: | 1629495973 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KUDARAVALLI | ||||||||
FirstName: | PRANEETH | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1120 15TH ST | ||||||||
Address2: |   | ||||||||
City: | AUGUSTA | ||||||||
State: | GA | ||||||||
PostalCode: | 309120004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7067218623 | ||||||||
FaxNumber: | 7067211459 | ||||||||
Practice Location | |||||||||
Address1: | 1120 15TH ST | ||||||||
Address2: |   | ||||||||
City: | AUGUSTA | ||||||||
State: | GA | ||||||||
PostalCode: | 309120004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7067218623 | ||||||||
FaxNumber: | 7067211459 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/25/2014 | ||||||||
LastUpdateDate: | 06/15/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/15/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 51420 | KY | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 88415 | GA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | 51420 | KY | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 208M00000X | 88415 | GA | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 13994135 | 01 |   | CAQH | OTHER |