Provider Demographics
NPI:1710151378
Name:ALURI, KALYAN CC (MD)
Entity Type:Individual
Prefix:
First Name:KALYAN
Middle Name:CC
Last Name:ALURI
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 1:1234 E DUPONT RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-373-9700
Mailing Address - Fax:260-373-9740
Practice Address - Street 1:3909 NEW VISION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1725
Practice Address - Country:US
Practice Address - Phone:260-469-6602
Practice Address - Fax:260-969-3065
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT187098207Q00000X
AZ40518207Q00000X
IN01064978A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ345978Medicaid
AZZ21113Medicare Oscar/Certification
AZZ21130Medicare Oscar/Certification
031806Medicare Oscar/Certification
Z123061Medicare PIN
AZ031822Medicare Oscar/Certification
Z21116Medicare PIN
AZ345978Medicaid
Z21114Medicare Oscar/Certification
AZ031805Medicare Oscar/Certification
Z123060Medicare PIN
Z21115Medicare Oscar/Certification
AZ031824Medicare Oscar/Certification
Z123059Medicare PIN