Healthcare Provider Details

I. General information

NPI: 1104810142
Provider Name (Legal Business Name): KRISHNA RAO KUDARAVALLI M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 01/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 MEDICAL PARK BOULEVARD SUITE 150
PETERSBURG VA
23805-9274
US

IV. Provider business mailing address

436 CLAIRMONT CT STE 105
COLONIAL HEIGHTS VA
23834-1765
US

V. Phone/Fax

Practice location:
  • Phone: 804-765-5206
  • Fax: 804-765-5809
Mailing address:
  • Phone: 804-765-5206
  • Fax: 804-765-5809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0101033170
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: