Provider Demographics
NPI:1881635118
Name:KODALI, MANGA DEVI (MD)
Entity Type:Individual
Prefix:DR
First Name:MANGA
Middle Name:DEVI
Last Name:KODALI
Suffix:
Gender:F
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:PO BOX 3868
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47737-3868
Mailing Address - Country:US
Mailing Address - Phone:812-450-6815
Mailing Address - Fax:812-450-6822
Practice Address - Street 1:4055 GATEWAY BLVD
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-8947
Practice Address - Country:US
Practice Address - Phone:812-858-3051
Practice Address - Fax:812-858-3060
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17645207R00000X
FLME99614207R00000X
IN01072479A207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00126843Medicaid
FL279823900Medicaid
MS110001595Medicare ID - Type UnspecifiedMEDICARE
FL279823900Medicaid
FLAG968XMedicare PIN
FLAG968WMedicare PIN
MS00126843Medicaid