Provider Demographics
NPI:1669760468
Name:VITTALA, KANTI SRI (MD)
Entity type:Individual
Prefix:DR
First Name:KANTI
Middle Name:SRI
Last Name:VITTALA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SATYA
Other - Middle Name:S
Other - Last Name:VITTALA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1790 S VILLAS LN
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85286-8416
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 S DOBSON RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-4707
Practice Address - Country:US
Practice Address - Phone:480-412-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-13
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ50690208000000X
CAA128129208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program