Provider Demographics
NPI:1043208978
Name:KANAMALLA, UDAY S (MD)
Entity Type:Individual
Prefix:
First Name:UDAY
Middle Name:S
Last Name:KANAMALLA
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 1:816 W CANNON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3194
Mailing Address - Country:US
Mailing Address - Phone:817-321-0404
Mailing Address - Fax:
Practice Address - Street 1:12700 PARK CENTRAL DR
Practice Address - Street 2:SUITE 430
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75251-1500
Practice Address - Country:US
Practice Address - Phone:972-239-8902
Practice Address - Fax:972-661-2551
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP31772085R0204X, 2085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB160494Medicare PIN
H62114Medicare UPIN