Provider Demographics
NPI:1285644104
Name:KODURU, BANERJE (MD)
Entity Type:Individual
Prefix:DR
First Name:BANERJE
Middle Name:
Last Name:KODURU
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 1:207 N 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOPEWELL
Mailing Address - State:VA
Mailing Address - Zip Code:23860-2503
Mailing Address - Country:US
Mailing Address - Phone:804-541-0918
Mailing Address - Fax:804-541-7924
Practice Address - Street 1:207 N 4TH AVE
Practice Address - Street 2:
Practice Address - City:HOPEWELL
Practice Address - State:VA
Practice Address - Zip Code:23860-2503
Practice Address - Country:US
Practice Address - Phone:804-541-0918
Practice Address - Fax:804-541-7924
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA010103000862084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007140436Medicaid
VA007140436Medicaid