MEDICARE: MRS. VIMALA NADINE KUKUNOOR M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	34515	AZ

General Provider Information

NPI Number	:	1063477495
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. VIMALA NADINE KUKUNOOR M.D.

Provider Business Mailing Address
First Line	:	2500 W UTOPIA RD
Second Line	:	STE. 100
City	:	PHOENIX
State	:	AZ
Zip	:	85027-4171
Country	:	US
Telephone Number	:	602-214-6148
Fax Number	:	602-214-6149

Provider Business Practice Location Address
First Line	:	9100 N 2ND ST
Second Line	:	SUITE 121
City	:	PHOENIX
State	:	AZ
Zip	:	85020-2446
Country	:	US
Telephone Number	:	602-997-7331
Fax Number	:	602-870-4512

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/19/2006
Last Update Date	:	09/24/2013

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