Provider Demographics
NPI:1942594924
Name:PUDOTA, KINGSLEY PRAKASH ANAND (MD)
Entity Type:Individual
Prefix:DR
First Name:KINGSLEY
Middle Name:PRAKASH ANAND
Last Name:PUDOTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3110 MACCORKLE AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1210
Mailing Address - Country:US
Mailing Address - Phone:304-388-5590
Mailing Address - Fax:304-388-8238
Practice Address - Street 1:3110 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1210
Practice Address - Country:US
Practice Address - Phone:304-388-5590
Practice Address - Fax:304-388-8238
Is Sole Proprietor?:No
Enumeration Date:2011-06-07
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101256996207R00000X
NC2015-02195208M00000X, 207R00000X
WV25957207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine