Provider Demographics
NPI:1891744603
Name:KODURI, PRASHANTHI BORA (MD)
Entity Type:Individual
Prefix:DR
First Name:PRASHANTHI
Middle Name:BORA
Last Name:KODURI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3920 BRIDGE RD
Mailing Address - Street 2:BLDG A, STE. 207
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-1117
Mailing Address - Country:US
Mailing Address - Phone:757-983-2200
Mailing Address - Fax:757-923-2201
Practice Address - Street 1:3920 BRIDGE RD
Practice Address - Street 2:BLDG A, STE. 207
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-1117
Practice Address - Country:US
Practice Address - Phone:757-983-2200
Practice Address - Fax:757-923-2201
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101229036207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10048061Medicaid
VA10048061Medicaid
VA000911012Medicare ID - Type Unspecified