Basic Information
| Provider Information | |||||||||
| NPI: | 1891993994 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KONANUR | ||||||||
| FirstName: | INDIRA | ||||||||
| MiddleName: | DORIS | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 779 | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941047001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4156586791 | ||||||||
| FaxNumber: | 4155200904 | ||||||||
| Practice Location | |||||||||
| Address1: | 28 STATE ST | ||||||||
| Address2: | SUITE 2850 | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021091775 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179035009 | ||||||||
| FaxNumber: | 6179035009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2007 | ||||||||
| LastUpdateDate: | 09/06/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 14926 | NH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 243668 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 30228286 | 05 | NH | MEDICAID |