Healthcare Provider Details

I. General information

NPI: 1952358558
Provider Name (Legal Business Name): KAMALA S. MOKSHAGUNDAM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 BLUEGRASS AVE
LOUISVILLE KY
40215-1161
US

IV. Provider business mailing address

6801 DIXIE HWY SUITE 113E
LOUISVILLE KY
40258-3913
US

V. Phone/Fax

Practice location:
  • Phone: 502-367-3360
  • Fax: 502-367-3365
Mailing address:
  • Phone: 502-451-5855
  • Fax: 502-479-1409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number29106
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: