Provider Demographics
NPI:1700443728
Name:KANTAMNENI, LEELA SAMUDRA
Entity type:Individual
Prefix:
First Name:LEELA
Middle Name:SAMUDRA
Last Name:KANTAMNENI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10724 WILSHIRE BLVD APT 1403
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-4473
Mailing Address - Country:US
Mailing Address - Phone:424-333-4882
Mailing Address - Fax:
Practice Address - Street 1:301 GOVERNORS DR SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-5123
Practice Address - Country:US
Practice Address - Phone:256-551-4611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-24
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXU5011207R00000X
GA91552207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine