Provider Demographics
NPI:1124361944
Name:KANTHALA, TRISHLA REDDY (DO)
Entity type:Individual
Prefix:
First Name:TRISHLA
Middle Name:REDDY
Last Name:KANTHALA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 INDEPENDENCE DR
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-1616
Mailing Address - Country:US
Mailing Address - Phone:732-692-0542
Mailing Address - Fax:
Practice Address - Street 1:1692 OAK TREE RD
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-2853
Practice Address - Country:US
Practice Address - Phone:732-692-0542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS018881208100000X
NJ25MB10244400208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103343083-0002Medicaid
PA103343083-0001Medicaid
PA1124361944OtherINDEPENDENCE BC/AMERIHEALTH
PA003625574OtherHIGHMARK CHOICE/PREMIER BS/MEDICARE ADVANTAGE
PA588234J67OtherMEDICARE