Provider Demographics
NPI:1417020363
Name:KANKANALA, SAMBAIAH (MD)
Entity Type:Individual
Prefix:MR
First Name:SAMBAIAH
Middle Name:
Last Name:KANKANALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SAMBAIAH
Other - Middle Name:
Other - Last Name:KANKANALA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2430 W PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-3553
Mailing Address - Country:US
Mailing Address - Phone:575-628-5051
Mailing Address - Fax:575-628-0493
Practice Address - Street 1:5320 N LOVINGTON HWY
Practice Address - Street 2:
Practice Address - City:HOBBS
Practice Address - State:NM
Practice Address - Zip Code:88240-9139
Practice Address - Country:US
Practice Address - Phone:575-392-1973
Practice Address - Fax:575-392-2030
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM81240207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM12021Medicaid
NMNM001X04OtherBCBS
C97875Medicare UPIN
NM12021Medicaid