Provider Demographics
NPI:1235140567
Name:PENDURTHI, KAVITA (MD)
Entity Type:Individual
Prefix:MRS
First Name:KAVITA
Middle Name:
Last Name:PENDURTHI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KAVITA
Other - Middle Name:
Other - Last Name:YALAMANCHILI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:600 E 5TH ST
Mailing Address - Street 2:FULTON STATE HOSPITAL
Mailing Address - City:FULTON
Mailing Address - State:MO
Mailing Address - Zip Code:65251-1753
Mailing Address - Country:US
Mailing Address - Phone:573-592-4100
Mailing Address - Fax:573-592-3023
Practice Address - Street 1:600 E 5TH ST
Practice Address - Street 2:FULTON STATE HOSPITAL
Practice Address - City:FULTON
Practice Address - State:MO
Practice Address - Zip Code:65251-1753
Practice Address - Country:US
Practice Address - Phone:573-592-4100
Practice Address - Fax:573-592-3023
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMO1006912084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208219501Medicaid
MO208219501Medicaid
MO077050022Medicare PIN