Provider Demographics
NPI:1679832463
Name:GORANTLA, KALYAN CHOWDARY (MD)
Entity Type:Individual
Prefix:DR
First Name:KALYAN
Middle Name:CHOWDARY
Last Name:GORANTLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:1704 LAFAYETTE RD STE 5
Practice Address - Street 2:
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-1071
Practice Address - Country:US
Practice Address - Phone:765-361-3011
Practice Address - Fax:765-362-5540
Is Sole Proprietor?:No
Enumeration Date:2012-05-14
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01082863A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300031050Medicaid