Basic Information
| Provider Information | |||||||||
| NPI: | 1558304725 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KANDULA | ||||||||
| FirstName: | MANJU | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 501123 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631500001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152841400 | ||||||||
| FaxNumber: | 6152841535 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 20TH AVE N | ||||||||
| Address2: | 9TH FLOOR | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372032131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152841400 | ||||||||
| FaxNumber: | 6152841535 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 05/05/2008 | ||||||||
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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 | 2084N0400X | 23757 | TN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 5152045 | 01 | TN | AETNA | OTHER | 130024217 | 01 | TN | RR MEDICARE | OTHER | 3096859 | 05 | TN | MEDICAID | 4018251 | 01 | TN | BLUE CROSS BLUE SHIELD | OTHER |