Provider Demographics
NPI:1356580054
Name:KANKANALA, SUCHARITHA (MD)
Entity type:Individual
Prefix:
First Name:SUCHARITHA
Middle Name:
Last Name:KANKANALA
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 CASSOTTA LN
Mailing Address - Street 2:
Mailing Address - City:SUFFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06078-1382
Mailing Address - Country:US
Mailing Address - Phone:413-464-9025
Mailing Address - Fax:409-772-8709
Practice Address - Street 1:401 YOUNG AVE STE 245B
Practice Address - Street 2:
Practice Address - City:MOORESTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08057-3132
Practice Address - Country:US
Practice Address - Phone:856-727-0900
Practice Address - Fax:856-231-8428
Is Sole Proprietor?:No
Enumeration Date:2009-02-19
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD453042207RE0101X, 207R00000X
NJ25MA09643100207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0478741Medicaid