Provider Demographics
NPI:1003432816
Name:BANALA, KEERTHANA REDDY
Entity Type:Individual
Prefix:
First Name:KEERTHANA REDDY
Middle Name:
Last Name:BANALA
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 1:1611 NW 12TH AVE # 6006
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:305-585-6017
Mailing Address - Fax:305-325-0293
Practice Address - Street 1:1611 NW 12TH AVE # 6006
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1005
Practice Address - Country:US
Practice Address - Phone:305-585-6017
Practice Address - Fax:305-325-0293
Is Sole Proprietor?:No
Enumeration Date:2020-06-18
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME162448208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208000000XAllopathic & Osteopathic PhysiciansPediatrics