Provider Demographics
NPI:1770901175
Name:MEDEPALLI, KANTHA (MD)
Entity type:Individual
Prefix:
First Name:KANTHA
Middle Name:
Last Name:MEDEPALLI
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 1:1611 NW 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1005
Mailing Address - Country:US
Mailing Address - Phone:305-585-5215
Mailing Address - Fax:305-585-8137
Practice Address - Street 1:209 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4265
Practice Address - Country:US
Practice Address - Phone:253-596-3300
Practice Address - Fax:253-596-3301
Is Sole Proprietor?:No
Enumeration Date:2014-04-02
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1770901175390200000X
OH57.024484207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program