Provider Demographics
NPI:1427095736
Name:KANDULA, RENUKA (MD)
Entity type:Individual
Prefix:
First Name:RENUKA
Middle Name:
Last Name:KANDULA
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 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-446-5131
Mailing Address - Fax:740-446-5486
Practice Address - Street 1:100 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1560
Practice Address - Country:US
Practice Address - Phone:740-446-5131
Practice Address - Fax:740-446-5486
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20268207R00000X
OH35.074211207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000006517OtherANTHEM BCBS
001714104OtherMOUNTAIN STATE BCBS
110166885OtherRR MEDICARE
OH000000181874OtherUNISON MEDICAID
OH2061512OtherOH MEDICAID MOLINA
WV0081952000Medicaid
OH2061512Medicaid
OH310917085106OtherCARESOURCE MEDICAID
WV0855132Medicare PIN
001714104OtherMOUNTAIN STATE BCBS
OH0855133Medicare PIN