Provider Demographics
NPI:1235248477
Name:BASARAKODU, KRISHNAMOHAN REDDY (MD)
Entity Type:Individual
Prefix:
First Name:KRISHNAMOHAN
Middle Name:REDDY
Last Name:BASARAKODU
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 1:1400 AFFLINK PLACE, SUITE 100
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35406
Mailing Address - Country:US
Mailing Address - Phone:205-366-9740
Mailing Address - Fax:205-344-9992
Practice Address - Street 1:1118 ROSS CLARK CIR STE 200
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301
Practice Address - Country:US
Practice Address - Phone:334-944-4673
Practice Address - Fax:334-712-3309
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007001544207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H77427Medicare UPIN