Provider Demographics
NPI:1740037506
Name:KONDURU, SIVA KRISHNA PRASAD
Entity type:Individual
Prefix:
First Name:SIVA KRISHNA PRASAD
Middle Name:
Last Name:KONDURU
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 1:10330 LEGACY HL
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-4480
Mailing Address - Country:US
Mailing Address - Phone:772-240-6270
Mailing Address - Fax:
Practice Address - Street 1:10330 LEGACY HL
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-4480
Practice Address - Country:US
Practice Address - Phone:772-240-6270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-01
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP100873192085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology