Provider Demographics
NPI:1528035748
Name:SAMUDRA, KALYANI (MD)
Entity Type:Individual
Prefix:
First Name:KALYANI
Middle Name:
Last Name:SAMUDRA
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 413076
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84141-3076
Mailing Address - Country:US
Mailing Address - Phone:801-213-3900
Mailing Address - Fax:801-569-9718
Practice Address - Street 1:501 S CHIPETA WAY
Practice Address - Street 2:ARTEC SOUTH CAMPUS, SECOND FLOOR
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1222
Practice Address - Country:US
Practice Address - Phone:801-585-1575
Practice Address - Fax:801-569-9718
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6079971-12052084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT60799711200001OtherBLUE CROSS PROVIDER #
UT60799711200001OtherBLUE CROSS PROVIDER #