Provider Demographics
NPI:1083060347
Name:PAKALA, KEERTI
Entity Type:Individual
Prefix:
First Name:KEERTI
Middle Name:
Last Name:PAKALA
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:PO BOX 255228
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95865-5228
Mailing Address - Country:US
Mailing Address - Phone:800-740-0071
Mailing Address - Fax:
Practice Address - Street 1:2 MEDICAL PLAZA DR STE 200
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3042
Practice Address - Country:US
Practice Address - Phone:916-797-4715
Practice Address - Fax:916-797-4716
Is Sole Proprietor?:No
Enumeration Date:2016-05-05
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA165983207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program