Provider Demographics
NPI:1891771382
Name:KEDLAYA, INDIRA (MD)
Entity Type:Individual
Prefix:
First Name:INDIRA
Middle Name:
Last Name:KEDLAYA
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 1:1600 N GRAND AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2755
Mailing Address - Country:US
Mailing Address - Phone:719-545-9292
Mailing Address - Fax:719-545-9191
Practice Address - Street 1:1600 N GRAND AVE STE 120
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2755
Practice Address - Country:US
Practice Address - Phone:719-545-9292
Practice Address - Fax:719-545-9191
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA067008207R00000X
CO44387207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO33471231Medicaid
COC808621Medicare PIN