Basic Information
| Provider Information | |||||||||
| NPI: | 1346668555 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KANDAGATLA | ||||||||
| FirstName: | PRIDVI | ||||||||
| MiddleName: | GAUTHAM | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4200 DAHLBERG DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554224841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525125600 | ||||||||
| FaxNumber: | 9525125651 | ||||||||
| Practice Location | |||||||||
| Address1: | 1983 SLOAN PL STE 11 | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551172004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513121620 | ||||||||
| FaxNumber: | 6513121570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2014 | ||||||||
| LastUpdateDate: | 06/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208C00000X | 71756 | MN | Y | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.