Healthcare Provider Details

I. General information

NPI: 1205194438
Provider Name (Legal Business Name): MADHUBINDU KANNEGANTI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2012
Last Update Date: 02/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13677 W MCDOWELL RD
GOODYEAR AZ
85395-2635
US

IV. Provider business mailing address

1501 KINGS HWY INTERNAL MEDICINE
SHREVEPORT LA
71103-4228
US

V. Phone/Fax

Practice location:
  • Phone: 623-882-1500
  • Fax:
Mailing address:
  • Phone: 318-813-2528
  • Fax: 318-813-2565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number50036
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: