Provider Demographics
NPI:1659608214
Name:KODURI, BRAHMANANDA KIRAN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRAHMANANDA
Middle Name:KIRAN
Last Name:KODURI
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 1:4516 RUNNING W DR APT 101
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82718-2033
Mailing Address - Country:US
Mailing Address - Phone:609-216-0537
Mailing Address - Fax:
Practice Address - Street 1:501 S BURMA AVE
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-3426
Practice Address - Country:US
Practice Address - Phone:307-688-1534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-03
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY9302A2080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine