Provider Demographics
NPI:1891993994
Name:KONANUR, INDIRA DORIS (DO)
Entity type:Individual
Prefix:
First Name:INDIRA
Middle Name:DORIS
Last Name:KONANUR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 779
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94104-7001
Mailing Address - Country:US
Mailing Address - Phone:415-658-6791
Mailing Address - Fax:415-520-0904
Practice Address - Street 1:28 STATE ST
Practice Address - Street 2:SUITE 2850
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02109-1775
Practice Address - Country:US
Practice Address - Phone:617-903-5009
Practice Address - Fax:617-903-5009
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH14926207R00000X
MA243668207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30228286Medicaid
NH30228286Medicaid