Provider Demographics
NPI:1679035570
Name:CHERUKURI, KAVISYA
Entity Type:Individual
Prefix:
First Name:KAVISYA
Middle Name:
Last Name:CHERUKURI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:257 FLATBUSH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-1066
Mailing Address - Country:US
Mailing Address - Phone:718-838-9445
Mailing Address - Fax:212-202-7988
Practice Address - Street 1:257 FLATBUSH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-1066
Practice Address - Country:US
Practice Address - Phone:718-838-9445
Practice Address - Fax:212-202-7988
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY317465208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program