Provider Demographics
NPI:1770819591
Name:KOMMURI, ANAND (MBBS,MD)
Entity Type:Individual
Prefix:DR
First Name:ANAND
Middle Name:
Last Name:KOMMURI
Suffix:
Gender:M
Credentials:MBBS,MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 E 54TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-7214
Mailing Address - Country:US
Mailing Address - Phone:536-323-1229
Mailing Address - Fax:
Practice Address - Street 1:1801 E 54TH ST
Practice Address - Street 2:STE 100
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-7209
Practice Address - Country:US
Practice Address - Phone:536-323-1229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-29
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA41045207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1770819591Medicaid
IA1770819591Medicaid