Provider Demographics
NPI:1457919417
Name:KODUKULA, KAMALA
Entity Type:Individual
Prefix:
First Name:KAMALA
Middle Name:
Last Name:KODUKULA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3180 NEWBERRY DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95118-1564
Mailing Address - Country:US
Mailing Address - Phone:408-961-9871
Mailing Address - Fax:
Practice Address - Street 1:1400 PARKMOOR AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-3797
Practice Address - Country:US
Practice Address - Phone:408-961-9871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA16897114198OtherMEDICAL