Provider Demographics
NPI:1104810142
Name:KUDARAVALLI, KRISHNA RAO (MD)
Entity type:Individual
Prefix:DR
First Name:KRISHNA
Middle Name:RAO
Last Name:KUDARAVALLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:436 CLAIRMONT CT STE 105
Mailing Address - Street 2:
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-1765
Mailing Address - Country:US
Mailing Address - Phone:804-765-5206
Mailing Address - Fax:804-765-5809
Practice Address - Street 1:210 MEDICAL PARK BOULEVARD
Practice Address - Street 2:SUITE 150
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9274
Practice Address - Country:US
Practice Address - Phone:804-765-5206
Practice Address - Fax:804-765-5809
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101033170207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006205411Medicaid
VAG59550Medicare UPIN
VA160001876Medicare PIN