Provider Demographics
NPI:1477745800
Name:KODALI, DHATRI (MD)
Entity Type:Individual
Prefix:DR
First Name:DHATRI
Middle Name:
Last Name:KODALI
Suffix:
Gender:F
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:PO BOX 911230
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1230
Mailing Address - Country:US
Mailing Address - Phone:972-997-8000
Mailing Address - Fax:972-437-9605
Practice Address - Street 1:501 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4219
Practice Address - Country:US
Practice Address - Phone:281-332-7505
Practice Address - Fax:281-332-7616
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM8770207R00000X, 207RX0202X, 207RH0003X
MN18684207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX193079401Medicaid
TX193079405Medicaid
TXP00662594OtherRAILROAD MEDICARE
TX193079402Medicaid
TX193079403Medicaid
TX8AQ003OtherBCBS
TX8K7969Medicare PIN
TX193079403Medicaid
TX397900YY6DMedicare PIN