Provider Demographics
NPI:1619957339
Name:KAMINENI, SUDHA (MD)
Entity Type:Individual
Prefix:
First Name:SUDHA
Middle Name:
Last Name:KAMINENI
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 1:1840 S STAPLEY DR
Mailing Address - Street 2:101
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-6681
Mailing Address - Country:US
Mailing Address - Phone:480-464-8500
Mailing Address - Fax:
Practice Address - Street 1:1840 S STAPLEY DR
Practice Address - Street 2:101
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-6681
Practice Address - Country:US
Practice Address - Phone:480-464-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28880207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ270223Medicaid
AZ270223Medicaid
AZ63399Medicare ID - Type Unspecified