Basic Information
| Provider Information | |||||||||
| NPI: | 1578769303 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KANNEGANTI | ||||||||
| FirstName: | KALYAN | ||||||||
| MiddleName: | CHAKRAVARTHY | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1112 6TH AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532728664 | ||||||||
| FaxNumber: | 2538746089 | ||||||||
| Practice Location | |||||||||
| Address1: | 1112 6TH AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532728664 | ||||||||
| FaxNumber: | 2538746089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2007 | ||||||||
| LastUpdateDate: | 12/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 002851 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | 002851 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | Q0286 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | MD60783086 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 2096205 | 05 | WA | MEDICAID |