Provider Demographics
NPI:1003073784
Name:KUDAKANDIRA, JYOTHI B (MD)
Entity Type:Individual
Prefix:DR
First Name:JYOTHI
Middle Name:B
Last Name:KUDAKANDIRA
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 1:1770 GRAND CONCOURSE
Mailing Address - Street 2:APT11M
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-5524
Mailing Address - Country:US
Mailing Address - Phone:610-618-6761
Mailing Address - Fax:
Practice Address - Street 1:1650 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-7606
Practice Address - Country:US
Practice Address - Phone:718-960-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-20
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD437609207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KU2137735OtherHIGHMARK BCBS
PA3751918000OtherINDEPENDENCE BCBS
PA089603Medicare PIN