Healthcare Provider Details

I. General information

NPI: 1376823567
Provider Name (Legal Business Name): SREENATH KODALI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2011
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 DUFF AVE
AMES IA
50010
US

IV. Provider business mailing address

1215 DUFF AVE
AMES IA
50010-5400
US

V. Phone/Fax

Practice location:
  • Phone: 515-239-4401
  • Fax: 515-239-4791
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number60 280695
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number45840
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: