Provider Demographics
NPI:1225082670
Name:KANDULA, PRADEEP K (MD)
Entity Type:Individual
Prefix:
First Name:PRADEEP
Middle Name:K
Last Name:KANDULA
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 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-446-5371
Mailing Address - Fax:740-446-5711
Practice Address - Street 1:100 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1560
Practice Address - Country:US
Practice Address - Phone:740-446-5371
Practice Address - Fax:740-446-5711
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.073733208000000X
WV19937208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
370009999OtherRR MEDICARE
000000006496OtherANTHEM BCBS
WV0111254000Medicaid
OH2048108OtherMOLINA MEDICAID
OH310917085048OtherCARESOURCE MEDICAID
OH000000181956OtherUNISON MEDICAID
001714099OtherMOUNTAIN STATE BCBS
OH2048108Medicaid
370009999OtherRR MEDICARE
WV0111254000Medicaid
OH0838083Medicare PIN