Healthcare Provider Details

I. General information

NPI: 1235248477
Provider Name (Legal Business Name): KRISHNAMOHAN REDDY BASARAKODU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 04/25/2025
Certification Date: 04/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1108 ROSS CLARK CIR
DOTHAN AL
36301-3022
US

IV. Provider business mailing address

1400 AFFLINK PLACE, SUITE 100
TUSCALOOSA AL
35406
US

V. Phone/Fax

Practice location:
  • Phone: 334-944-4673
  • Fax: 334-712-3309
Mailing address:
  • Phone: 205-366-9740
  • Fax: 205-344-9992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number2007001544
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: