Provider Demographics
NPI:1558672253
Name:KODURI, VIJAYA MADHAVI (MBBS)
Entity Type:Individual
Prefix:DR
First Name:VIJAYA
Middle Name:MADHAVI
Last Name:KODURI
Suffix:
Gender:F
Credentials:MBBS
Other - Prefix:DR
Other - First Name:VIJAYA
Other - Middle Name:MADHAVI
Other - Last Name:PINNAMANENI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MBBS
Mailing Address - Street 1:PO BOX 3046
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82717-3046
Mailing Address - Country:US
Mailing Address - Phone:307-688-2600
Mailing Address - Fax:307-685-3079
Practice Address - Street 1:1252 N 22ND ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072-5306
Practice Address - Country:US
Practice Address - Phone:307-745-3704
Practice Address - Fax:307-745-7237
Is Sole Proprietor?:No
Enumeration Date:2010-06-28
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY9303A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics