Healthcare Provider Details

I. General information

NPI: 1194413906
Provider Name (Legal Business Name): SRUTI KALLA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2023
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 E THOMAS RD
PHOENIX AZ
85016-7710
US

IV. Provider business mailing address

400 E EARLL DR UNIT 628
PHOENIX AZ
85012-0034
US

V. Phone/Fax

Practice location:
  • Phone: 602-933-1000
  • Fax:
Mailing address:
  • Phone: 650-278-3450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: