MEDICARE: DR. SURESH KANKANALA 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	N5145	TX
2	390200000X	Student in an Organized Health Care Education/Training Program	57-011410	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922211697
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SURESH KANKANALA M.D.

Provider Business Mailing Address
First Line	:	1023 LIPSCOMB ST STE 200
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-3130
Country	:	US
Telephone Number	:	972-544-6600
Fax Number	:	972-544-6604

Provider Business Practice Location Address
First Line	:	1023 LIPSCOMB ST STE 200
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-3130
Country	:	US
Telephone Number	:	972-544-6600
Fax Number	:	972-544-6604

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

Provider Enumeration Date	:	05/08/2007
Last Update Date	:	04/05/2022

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