Provider Demographics
NPI:1558365445
Name:KALLURI, PRAKASAM (MD)
Entity type:Individual
Prefix:DR
First Name:PRAKASAM
Middle Name:
Last Name:KALLURI
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 1:815 W POYTHRESS ST
Mailing Address - Street 2:
Mailing Address - City:HOPEWELL
Mailing Address - State:VA
Mailing Address - Zip Code:23860-2532
Mailing Address - Country:US
Mailing Address - Phone:804-471-7730
Mailing Address - Fax:804-471-7731
Practice Address - Street 1:815 W POYTHRESS ST
Practice Address - Street 2:
Practice Address - City:HOPEWELL
Practice Address - State:VA
Practice Address - Zip Code:23860-2532
Practice Address - Country:US
Practice Address - Phone:804-471-7730
Practice Address - Fax:804-471-7731
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101237849207X00000X, 207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010185238Medicaid
VA0101237849OtherSTATE LICENSE
VAP00237625OtherRAILROAD MEDICARE
VAP00237625OtherRAILROAD MEDICARE
VAI38795Medicare UPIN
VA0603180002Medicare NSC