Healthcare Provider Details

I. General information

NPI: 1730762840
Provider Name (Legal Business Name): SUHIND KRISHNA DAS KODALI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2021
Last Update Date: 09/19/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2651 E DISCOVERY PKWY
BLOOMINGTON IN
47408-9059
US

IV. Provider business mailing address

6816 FORESTVIEW CT
WEST BLOOMFIELD MI
48322-4506
US

V. Phone/Fax

Practice location:
  • Phone: 812-676-4102
  • Fax: 812-373-4106
Mailing address:
  • Phone: 248-660-6623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01094293A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number4301509979
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: