Provider Demographics
NPI:1063772234
Name:KALLU, SWAPNA GAYATHRI (MD)
Entity type:Individual
Prefix:
First Name:SWAPNA
Middle Name:GAYATHRI
Last Name:KALLU
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 25807
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-2009
Mailing Address - Country:US
Mailing Address - Phone:804-559-6980
Mailing Address - Fax:804-559-6982
Practice Address - Street 1:8400 N RUN MEDICAL DR STE 200
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-2319
Practice Address - Country:US
Practice Address - Phone:804-559-6980
Practice Address - Fax:804-559-6982
Is Sole Proprietor?:No
Enumeration Date:2012-05-22
Last Update Date:2025-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101273025207RN0300X
LA206172207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2333097Medicaid
LA475450YJFFMedicare PIN