Provider Demographics
NPI:1114974979
Name:KATKURI, JITHANDER R (MD)
Entity Type:Individual
Prefix:
First Name:JITHANDER
Middle Name:R
Last Name:KATKURI
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 1:713A PRESIDENT PL
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-5652
Mailing Address - Country:US
Mailing Address - Phone:615-220-0056
Mailing Address - Fax:615-220-0456
Practice Address - Street 1:713A PRESIDENT PL
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-5652
Practice Address - Country:US
Practice Address - Phone:615-220-0056
Practice Address - Fax:615-220-0456
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000031779207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3132821Medicaid
TNG99345Medicare UPIN
TN3842978Medicare ID - Type UnspecifiedMEDICARE NUMBER