Provider Demographics
NPI:1730762840
Name:KODALI, SUHIND KRISHNA DAS (MD)
Entity type:Individual
Prefix:
First Name:SUHIND
Middle Name:KRISHNA DAS
Last Name:KODALI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6816 FORESTVIEW CT
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-4506
Mailing Address - Country:US
Mailing Address - Phone:248-660-6623
Mailing Address - Fax:
Practice Address - Street 1:2651 E DISCOVERY PKWY
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-9059
Practice Address - Country:US
Practice Address - Phone:812-676-4102
Practice Address - Fax:812-373-4106
Is Sole Proprietor?:No
Enumeration Date:2021-05-05
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01094293A207R00000X
MI4301509979208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300094997Medicaid
IN090540A23OtherMEDICARE PTAN
IN1104289588OtherANTHEM PTAN