Provider Demographics
NPI:1518058569
Name:KODALI, LAVANYA (MD)
Entity type:Individual
Prefix:DR
First Name:LAVANYA
Middle Name:
Last Name:KODALI
Suffix:
Gender:F
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:PO BOX 2005
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-4505
Mailing Address - Country:US
Mailing Address - Phone:315-449-0513
Mailing Address - Fax:315-362-5120
Practice Address - Street 1:1500 N JAMES ST
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-2844
Practice Address - Country:US
Practice Address - Phone:153-387-0003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY231455207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAK142-0001OtherCAREFIRST 2005
VA1518058569Medicaid
NY04193115Medicaid
VA484645OtherNCPPO
VA9385084OtherPHCS
VA033579OtherANTHEM
VA293961OtherAMERIGROUP
VAI09005Medicare UPIN
VA007810F81Medicare PIN