Provider Demographics
NPI:1942486568
Name:MIRYALA, REKHA (MD)
Entity Type:Individual
Prefix:
First Name:REKHA
Middle Name:
Last Name:MIRYALA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:REKHA
Other - Middle Name:
Other - Last Name:KALAKUNTHA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1018 BROAD STREET
Mailing Address - Street 2:SUITE 8
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-2884
Mailing Address - Country:US
Mailing Address - Phone:973-338-4900
Mailing Address - Fax:
Practice Address - Street 1:1018 BROAD STREET
Practice Address - Street 2:SUITE 8
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-2884
Practice Address - Country:US
Practice Address - Phone:973-338-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-14
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08463200207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0235067Medicaid
NJ193163ZC79Medicare PIN
NJ193163ZCBAMedicare PIN