Provider Demographics
NPI:1306078118
Name:KANUKUNTLA, TULASI (MD)
Entity type:Individual
Prefix:
First Name:TULASI
Middle Name:
Last Name:KANUKUNTLA
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 1:52 GRAVITY
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-1702
Mailing Address - Country:US
Mailing Address - Phone:913-909-8310
Mailing Address - Fax:
Practice Address - Street 1:1809 W REDLANDS BLVD STE 103
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-8054
Practice Address - Country:US
Practice Address - Phone:909-289-4075
Practice Address - Fax:909-363-8233
Is Sole Proprietor?:No
Enumeration Date:2009-08-12
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN559322084P0800X
KS94-07296390200000X
CAC1540322084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program