Provider Demographics
NPI:1518058569
Name:KODALI, LAVANYA (MD)
Entity Type:Individual
Prefix:DR
First Name:LAVANYA
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 1:3998 FAIR RIDGE DR
Mailing Address - Street 2:STE 300
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2921
Mailing Address - Country:US
Mailing Address - Phone:703-766-9737
Mailing Address - Fax:703-766-9725
Practice Address - Street 1:3600 JOSEPH SIEWICK DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1709
Practice Address - Country:US
Practice Address - Phone:703-391-3129
Practice Address - Fax:703-295-9369
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101236616207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA293961OtherAMERIGROUP
VA033579OtherANTHEM
VA484645OtherNCPPO
VA9385084OtherPHCS
VAK142-0001OtherCAREFIRST 2005
VA1518058569Medicaid
VA9385084OtherPHCS
VAI09005Medicare UPIN
VA007810F81Medicare PIN