Provider Demographics
NPI:1750738860
Name:KODALI, DEEPTHI (MD)
Entity type:Individual
Prefix:
First Name:DEEPTHI
Middle Name:
Last Name:KODALI
Suffix:
Gender:F
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:PO BOX 749495
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-9495
Mailing Address - Country:US
Mailing Address - Phone:394-328-3312
Mailing Address - Fax:813-321-1296
Practice Address - Street 1:13424 E MISSION AVE STE A
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-2759
Practice Address - Country:US
Practice Address - Phone:509-462-2273
Practice Address - Fax:509-462-2275
Is Sole Proprietor?:No
Enumeration Date:2016-05-18
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAMD61351890207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program