Healthcare Provider Details

I. General information

NPI: 1205149432
Provider Name (Legal Business Name): STANKA MADHU KUMAR KANKIPATI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2010
Last Update Date: 03/03/2021
Certification Date: 03/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

661 MAHONING AVE NW
WARREN OH
44483-4607
US

IV. Provider business mailing address

6505 MARKET ST BLDG A1
BOARDMAN OH
44512-3457
US

V. Phone/Fax

Practice location:
  • Phone: 330-746-8040
  • Fax: 330-746-8025
Mailing address:
  • Phone: 330-746-8040
  • Fax: 330-746-8025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD449124
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD176098
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.135506
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: