MEDICARE: UDAY S KANAMALLA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0204X	Vascular & Interventional Radiology Physician	P3177	TX
2	2085N0700X	Neuroradiology Physician	P3177	TX

General Provider Information

NPI Number	:	1043208978
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	UDAY S KANAMALLA MD

Provider Business Mailing Address
First Line	:	816 W CANNON ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-3194
Country	:	US
Telephone Number	:	817-321-0404
Fax Number	:

Provider Business Practice Location Address
First Line	:	12700 PARK CENTRAL DR
Second Line	:	SUITE 430
City	:	DALLAS
State	:	TX
Zip	:	75251-1500
Country	:	US
Telephone Number	:	972-239-8902
Fax Number	:	972-661-2551

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/13/2005
Last Update Date	:	12/18/2023

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Directions to “ UDAY S KANAMALLA MD” Practice Location

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