Healthcare Provider Details

I. General information

NPI: 1609991207
Provider Name (Legal Business Name): KALYAN CHAKRAVARTHY VUNNAMADALA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1923 S UTICA AVE FL 5
TULSA OK
74104-6520
US

IV. Provider business mailing address

920 E 1ST ST STE 303
DULUTH MN
55805-2225
US

V. Phone/Fax

Practice location:
  • Phone: 918-712-3366
  • Fax: 918-403-6343
Mailing address:
  • Phone: 218-249-6050
  • Fax: 218-249-6055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number44780
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberMD-42919
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number73347
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number12011
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: