Healthcare Provider Details

I. General information

NPI: 1053477372
Provider Name (Legal Business Name): SRIDEVI KONKIMALLA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 05/04/2021
Certification Date: 05/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3765 S ALAMEDA ST STE 304
CORPUS CHRISTI TX
78411-1671
US

IV. Provider business mailing address

PO BOX 61160
CORPUS CHRISTI TX
78466-1160
US

V. Phone/Fax

Practice location:
  • Phone: 361-884-2904
  • Fax: 361-884-2919
Mailing address:
  • Phone: 361-884-2904
  • Fax: 361-857-0572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMT187482
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number7846
License Number StateSD
# 3
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberR3894
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: