Provider Demographics
NPI:1417012030
Name:KAKARALA, RENUKA
Entity Type:Individual
Prefix:DR
First Name:RENUKA
Middle Name:
Last Name:KAKARALA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 GRAMPIAN BLVD
Mailing Address - Street 2:SUITE 1K
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:904 CAMPBELL ST
Practice Address - Street 2:SUITE 102
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-3154
Practice Address - Country:US
Practice Address - Phone:570-321-2284
Practice Address - Fax:570-321-2477
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD423674207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1021943900001Medicaid
PA9849152OtherAETNA
PA1646618OtherHIGHMARK BLUE SHIELD
PA003172OtherFIRST PRIORITY HEALTH
PAP00645981Medicare PIN