Provider Demographics
NPI:1093722977
Name:KONDAPANENI, KISHORE B (MD)
Entity Type:Individual
Prefix:MR
First Name:KISHORE
Middle Name:B
Last Name:KONDAPANENI
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 1:690 S TRUMBULL
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48708
Mailing Address - Country:US
Mailing Address - Phone:989-922-4900
Mailing Address - Fax:989-922-4911
Practice Address - Street 1:690 S TRUMBULL
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708
Practice Address - Country:US
Practice Address - Phone:989-922-4900
Practice Address - Fax:989-922-4911
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010588572084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
2602960690OtherHEALTH PLUS
MIN34080004OtherMEDICARE
MI4318064Medicaid
5972098OtherAETNA
MI260Z910350OtherBCBS
MI90196OtherBCBS
MI4318064Medicaid