Provider Demographics
NPI:1164615829
Name:KALLU, PREETI (MD)
Entity Type:Individual
Prefix:DR
First Name:PREETI
Middle Name:
Last Name:KALLU
Suffix:
Gender:F
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:PO BOX 49106
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33743-9106
Mailing Address - Country:US
Mailing Address - Phone:727-269-5618
Mailing Address - Fax:727-265-3420
Practice Address - Street 1:508 S HABANA AVE STE 335
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-4186
Practice Address - Country:US
Practice Address - Phone:727-269-5618
Practice Address - Fax:727-265-3420
Is Sole Proprietor?:No
Enumeration Date:2007-08-24
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT185422207R00000X
FLME108938207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01276478OtherMEDICARE RAILROAD PROVIDER NUMBER
FL004191800Medicaid
FL004191800Medicaid