Provider Demographics
NPI:1861405748
Name:KODALI, SATISH (MD)
Entity type:Individual
Prefix:
First Name:SATISH
Middle Name:
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 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:DEPT OF OTOLARYNGOLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-5580
Mailing Address - Fax:414-805-8324
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:DEPT OF OTOLARYNGOLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-5580
Practice Address - Fax:414-805-8324
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI35593207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32411700Medicaid
WI1861405748Medicaid
G67796Medicare UPIN
WIP00288933Medicare PIN
WI000952360Medicare PIN
WI000901358Medicare PIN