Provider Demographics
NPI:1922211697
Name:KANKANALA, SURESH (MD)
Entity Type:Individual
Prefix:DR
First Name:SURESH
Middle Name:
Last Name:KANKANALA
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 1:1023 LIPSCOMB ST STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3130
Mailing Address - Country:US
Mailing Address - Phone:972-544-6600
Mailing Address - Fax:972-544-6604
Practice Address - Street 1:1023 LIPSCOMB ST STE 200
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3130
Practice Address - Country:US
Practice Address - Phone:972-544-6600
Practice Address - Fax:972-544-6604
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN5145207R00000X
OH57-011410390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX214605201Medicaid