Provider Demographics
NPI:1154397735
Name:KODALI, SRILATHA (MD)
Entity type:Individual
Prefix:DR
First Name:SRILATHA
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 1:49 ATWOOD RD STE 1
Mailing Address - Street 2:
Mailing Address - City:PELHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03076-3752
Mailing Address - Country:US
Mailing Address - Phone:603-635-2802
Mailing Address - Fax:603-635-3070
Practice Address - Street 1:49 ATWOOD RD
Practice Address - Street 2:SUITE 1
Practice Address - City:PELHAM
Practice Address - State:NH
Practice Address - Zip Code:03076-3719
Practice Address - Country:US
Practice Address - Phone:603-635-2802
Practice Address - Fax:603-635-3070
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-24
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA158755207R00000X
NH10537207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30200262Medicaid
MA3197352Medicaid
G91492Medicare UPIN
110227329Medicare ID - Type UnspecifiedRR MEDICARE
NHRE5241Medicare PIN