Provider Demographics
NPI:1578769303
Name:KANNEGANTI, KALYAN CHAKRAVARTHY (MD)
Entity Type:Individual
Prefix:
First Name:KALYAN
Middle Name:CHAKRAVARTHY
Last Name:KANNEGANTI
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 1:1112 6TH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4048
Mailing Address - Country:US
Mailing Address - Phone:253-272-8664
Mailing Address - Fax:253-874-6089
Practice Address - Street 1:1112 6TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4048
Practice Address - Country:US
Practice Address - Phone:253-272-8664
Practice Address - Fax:253-874-6089
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002851207R00000X, 207RG0100X
TXQ0286207RG0100X
WAMD60783086207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2096205Medicaid