Provider Demographics
NPI:1265515662
Name:KANDALA, JAGDESH (MD)
Entity type:Individual
Prefix:
First Name:JAGDESH
Middle Name:
Last Name:KANDALA
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 1:416 COLEGATE DR BLDG 3
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-9549
Mailing Address - Country:US
Mailing Address - Phone:740-568-4814
Mailing Address - Fax:740-374-3165
Practice Address - Street 1:400 MATTHEW ST STE 302
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-1656
Practice Address - Country:US
Practice Address - Phone:740-568-5207
Practice Address - Fax:740-568-5297
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.144262207RC0000X, 207RI0011X
NY290180207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30206340Medicaid
NHRE8907Medicare PIN