Provider Demographics
NPI:1548597289
Name:SREEDEVI KODALI, M.D., PLLC
Entity Type:Organization
Organization Name:SREEDEVI KODALI, M.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SREEDEVI
Authorized Official - Middle Name:
Authorized Official - Last Name:KODALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-868-1616
Mailing Address - Street 1:5209 HERITAGE AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-5987
Mailing Address - Country:US
Mailing Address - Phone:817-868-1616
Mailing Address - Fax:817-868-1617
Practice Address - Street 1:5209 HERITAGE AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-5987
Practice Address - Country:US
Practice Address - Phone:817-868-1616
Practice Address - Fax:817-868-1617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-16
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM6238261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty