Provider Demographics
NPI:1154385656
Name:KODALI, KIRTI R (MD)
Entity type:Individual
Prefix:
First Name:KIRTI
Middle Name:R
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 1:305 BICENTENNIAL HWY
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01118-1962
Mailing Address - Country:US
Mailing Address - Phone:413-733-4101
Mailing Address - Fax:413-789-8048
Practice Address - Street 1:305 BICENTENNIAL HWY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01118-1962
Practice Address - Country:US
Practice Address - Phone:413-733-4101
Practice Address - Fax:413-789-8048
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA60455208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3044076Medicaid
MAJ08174Medicare ID - Type Unspecified
MAB70753Medicare UPIN