Provider Demographics
NPI:1306814561
Name:RAO, KONDRAGANTI P (MD)
Entity Type:Individual
Prefix:DR
First Name:KONDRAGANTI
Middle Name:P
Last Name:RAO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:50 N DEEPLANDS ROAD
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48236
Mailing Address - Country:US
Mailing Address - Phone:586-573-0589
Mailing Address - Fax:586-573-3861
Practice Address - Street 1:28111 HOOVER
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093
Practice Address - Country:US
Practice Address - Phone:586-573-0589
Practice Address - Fax:586-573-3861
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301032931207LP2900X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2627454Medicaid
A79189Medicare UPIN
MI0822884Medicare ID - Type Unspecified