Provider Demographics
NPI:1699772889
Name:KANAGALA, PARDHA (MD)
Entity type:Individual
Prefix:DR
First Name:PARDHA
Middle Name:
Last Name:KANAGALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3702 NEW VISION DR
Mailing Address - Street 2:BLDG B
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1703
Mailing Address - Country:US
Mailing Address - Phone:260-266-8210
Mailing Address - Fax:
Practice Address - Street 1:3810 NEW VISION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1708
Practice Address - Country:US
Practice Address - Phone:260-482-1004
Practice Address - Fax:260-483-7894
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-01
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01028077A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000082092OtherANTHEM BC/BS
IN100322090AMedicaid
IN1461OtherPHP
IN046250QMedicare ID - Type Unspecified
IN1461OtherPHP