Provider Demographics
NPI:1285634931
Name:VALLAM, KIRAN KUMAR (MD)
Entity type:Individual
Prefix:
First Name:KIRAN
Middle Name:KUMAR
Last Name:VALLAM
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 1:317 N DELAWARE ST
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7750
Mailing Address - Country:US
Mailing Address - Phone:509-736-5550
Mailing Address - Fax:509-737-8281
Practice Address - Street 1:317 N DELAWARE ST
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7750
Practice Address - Country:US
Practice Address - Phone:509-736-5550
Practice Address - Fax:509-737-8281
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAFE00045283207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAFE00045283OtherMEDICAL LICENSE
WAPENDINGMedicare ID - Type Unspecified