Provider Demographics
NPI:1508179607
Name:KODALI, DHEERAJ (MD)
Entity Type:Individual
Prefix:
First Name:DHEERAJ
Middle Name:
Last Name:KODALI
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 1:2626 N CALIFORNIA ST STE B
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-5500
Mailing Address - Country:US
Mailing Address - Phone:209-466-2626
Mailing Address - Fax:209-466-7153
Practice Address - Street 1:2626 N CALIFORNIA ST STE B
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-5500
Practice Address - Country:US
Practice Address - Phone:209-466-2626
Practice Address - Fax:209-466-7153
Is Sole Proprietor?:No
Enumeration Date:2010-07-17
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV26214207RH0003X, 2084P0800X
CAA172284207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry