Healthcare Provider Details

I. General information

NPI: 1356580054
Provider Name (Legal Business Name): SUCHARITHA KANKANALA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2009
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 YOUNG AVE STE 245B
MOORESTOWN NJ
08057-3132
US

IV. Provider business mailing address

4 CASSOTTA LN
SUFFIELD CT
06078-1382
US

V. Phone/Fax

Practice location:
  • Phone: 856-727-0900
  • Fax: 856-231-8428
Mailing address:
  • Phone: 413-464-9025
  • Fax: 409-772-8709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberMD453042
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number25MA09643100
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD453042
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: