Provider Demographics
NPI:1669554218
Name:KODALI, SURYAM
Entity type:Individual
Prefix:DR
First Name:SURYAM
Middle Name:
Last Name:KODALI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7737 SOUTHWEST FWY STE 510
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77074-1800
Mailing Address - Country:US
Mailing Address - Phone:713-777-1141
Mailing Address - Fax:713-270-7714
Practice Address - Street 1:7737 SOUTHWEST FWY STE 510
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77074-1800
Practice Address - Country:US
Practice Address - Phone:713-777-1141
Practice Address - Fax:713-270-7714
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF2307174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX85G881Medicare ID - Type Unspecified
TXC17992Medicare UPIN