Provider Demographics
NPI:1417129610
Name:KADIYALA, DEEPAK (MD)
Entity Type:Individual
Prefix:
First Name:DEEPAK
Middle Name:
Last Name:KADIYALA
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 1:640 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-3297
Mailing Address - Country:US
Mailing Address - Phone:478-745-5455
Mailing Address - Fax:478-803-5232
Practice Address - Street 1:350 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-3838
Practice Address - Country:US
Practice Address - Phone:478-765-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-27
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT47678207R00000X
IN01071837207RN0300X
GA73309207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201129470Medicaid
IN201129470Medicaid