Provider Demographics
NPI:1336116565
Name:KONDAPALLI, PRASADARAO (MD)
Entity Type:Individual
Prefix:
First Name:PRASADARAO
Middle Name:
Last Name:KONDAPALLI
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 1:20525 CENTER RIDGE RD
Mailing Address - Street 2:STE 220
Mailing Address - City:ROCKY RIVER
Mailing Address - State:OH
Mailing Address - Zip Code:44116
Mailing Address - Country:US
Mailing Address - Phone:440-895-5056
Mailing Address - Fax:440-333-2935
Practice Address - Street 1:15000 MADISON AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-4014
Practice Address - Country:US
Practice Address - Phone:216-227-1595
Practice Address - Fax:216-227-9465
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35042650K207RP1001X
OH35042650207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0428504Medicaid
CA4511OtherGROUP RR MEDICARE
1780634279OtherGROUP NPI
D368301OtherGROUP IND DIAGNOSTICS MED
0119204OtherGROUP MEDICAID
3610861OtherGROUP ASC MEDICARE
9273172OtherGROUP MEDICARE
10794333OtherCAQH
109902OtherKAISER
109902OtherKAISER
3610861OtherGROUP ASC MEDICARE
D368301OtherGROUP IND DIAGNOSTICS MED