Provider Demographics
NPI:1376608059
Name:KANDALA, RAJIV (MD)
Entity Type:Individual
Prefix:DR
First Name:RAJIV
Middle Name:
Last Name:KANDALA
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 1:7531 S. STONY ISLAND AVE
Mailing Address - Street 2:#164
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649-3954
Mailing Address - Country:US
Mailing Address - Phone:773-947-2831
Mailing Address - Fax:773-947-7500
Practice Address - Street 1:7531 S. STONY ISLAND AVE
Practice Address - Street 2:#164
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-3954
Practice Address - Country:US
Practice Address - Phone:773-947-2831
Practice Address - Fax:773-947-7500
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-24
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036109208207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036109208Medicaid
IL208106Medicare ID - Type Unspecified
ILH88810Medicare UPIN