Healthcare Provider Details

I. General information

NPI: 1336645365
Provider Name (Legal Business Name): KEERTHI CHANNARASAPPA DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2018
Last Update Date: 12/07/2021
Certification Date: 12/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 CIVIC CENTER BLVD
PHILADELPHIA PA
19104-5127
US

IV. Provider business mailing address

962 N 8TH ST UNIT 7
PHILADELPHIA PA
19123-1304
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number58.030436
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS021587
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS0121587
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: