Healthcare Provider Details

I. General information

NPI: 1659514966
Provider Name (Legal Business Name): SMILA KODALI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2009
Last Update Date: 02/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 E MARKET ST
WARREN OH
44483-6608
US

IV. Provider business mailing address

1350 E MARKET ST
WARREN OH
44483-6608
US

V. Phone/Fax

Practice location:
  • Phone: 330-841-9011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberTP130
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: