Basic Information
| Provider Information | |||||||||
| NPI: | 1477745800 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KODALI | ||||||||
| FirstName: | DHATRI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 911230 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753911230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729978000 | ||||||||
| FaxNumber: | 9724379605 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 MEDICAL CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | WEBSTER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775984219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2813327505 | ||||||||
| FaxNumber: | 2813327616 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2007 | ||||||||
| LastUpdateDate: | 05/08/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | M8770 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0003X | 18684 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RX0202X | M8770 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207RH0003X | M8770 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 193079401 | 05 | TX | MEDICAID | 193079405 | 05 | TX | MEDICAID | P00662594 | 01 | TX | RAILROAD MEDICARE | OTHER | 193079402 | 05 | TX | MEDICAID | 193079403 | 05 | TX | MEDICAID | 8AQ003 | 01 | TX | BCBS | OTHER |