Basic Information
Provider Information | |||||||||
NPI: | 1033100797 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KAKARALA | ||||||||
FirstName: | MEENAKSHI | ||||||||
MiddleName: | HEMA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KAKARALA | ||||||||
OtherFirstName: | MEENA | ||||||||
OtherMiddleName: | HEMA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 790 CHURCH ST NE | ||||||||
Address2: | SUITE 250 | ||||||||
City: | MARIETTA | ||||||||
State: | GA | ||||||||
PostalCode: | 300607282 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6787978201 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 790 CHURCH ST NE | ||||||||
Address2: | SUITE 250 | ||||||||
City: | MARIETTA | ||||||||
State: | GA | ||||||||
PostalCode: | 300607282 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6787978201 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/02/2005 | ||||||||
LastUpdateDate: | 04/19/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME80724 | FL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 61974 | GA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 260861800 | 05 | FL |   | MEDICAID | 2508903 | 01 |   | AETNA HMO | OTHER | 3764898001 | 01 |   | CIGNA | OTHER |