Provider Demographics
NPI:1891748539
Name:KANDIMALLA, JITHENDER R (MD)
Entity Type:Individual
Prefix:
First Name:JITHENDER
Middle Name:R
Last Name:KANDIMALLA
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 1:655 WILL ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4236
Mailing Address - Country:US
Mailing Address - Phone:770-229-6072
Mailing Address - Fax:770-229-2111
Practice Address - Street 1:619 S 8TH ST STE 301
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4260
Practice Address - Country:US
Practice Address - Phone:770-229-6072
Practice Address - Fax:770-229-2111
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN52678208600000X
ND9950208600000X
GA072654208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA020002826Medicare PIN
MN020002826Medicare PIN