Provider Demographics
NPI:1972891463
Name:KOUKUNTLA, PADMA REKHA REKHA (MD)
Entity Type:Individual
Prefix:
First Name:PADMA REKHA
Middle Name:REKHA
Last Name:KOUKUNTLA
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 1:330 TURNER MCCALL BLVD SW STE 201
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-5634
Mailing Address - Country:US
Mailing Address - Phone:706-509-4340
Mailing Address - Fax:
Practice Address - Street 1:304 TURNER MCCALL BLVD SW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-5621
Practice Address - Country:US
Practice Address - Phone:706-509-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-18
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY276458207R00000X, 208M00000X
AL42633207R00000X
GA77417207R00000X
FLME 128519207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03001654/NWKMedicaid
NY01131126/RGHMedicaid
NY03941522Medicaid
NY10712A/NWKMedicare PIN
NY03001654/NWKMedicaid
NYJ400161356Medicare PIN
NY03941522Medicaid