Provider Demographics
NPI:1265494561
Name:KANDALLU, VENKATESH R (MD)
Entity Type:Individual
Prefix:DR
First Name:VENKATESH
Middle Name:R
Last Name:KANDALLU
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 1:202 N DIVISION ST
Mailing Address - Street 2:STE 201
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98001-4939
Mailing Address - Country:US
Mailing Address - Phone:253-939-1230
Mailing Address - Fax:253-735-1211
Practice Address - Street 1:205 10TH ST NE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-4019
Practice Address - Country:US
Practice Address - Phone:253-939-1230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00035482207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0280779OtherSTATE L&I
WA0280798OtherSTATE L&I
WA0280788OtherSTATE L&I
WA8214868Medicaid
WA0280788OtherSTATE L&I
WA0280798OtherSTATE L&I
WA8214868Medicaid