Provider Demographics
NPI:1437399037
Name:SURESH KODALI
Entity Type:Organization
Organization Name:SURESH KODALI
Other - Org Name:DOCTOR KODALI & ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:SURESH
Authorized Official - Middle Name:B
Authorized Official - Last Name:KODALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-766-1234
Mailing Address - Street 1:708 WESTPORT RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-3819
Mailing Address - Country:US
Mailing Address - Phone:270-766-1234
Mailing Address - Fax:270-766-1144
Practice Address - Street 1:708 WESTPORT RD
Practice Address - Street 2:SUITE 103
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-3819
Practice Address - Country:US
Practice Address - Phone:270-766-1234
Practice Address - Fax:270-766-1144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-23
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0726106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty