Basic Information
| Provider Information | |||||||||
| NPI: | 1629067533 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KANCHARLA | ||||||||
| FirstName: | KIRAN | ||||||||
| MiddleName: | REDDY | ||||||||
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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: | 9722342987 | ||||||||
| Practice Location | |||||||||
| Address1: | 2021 N MACARTHUR BLVD STE 400 | ||||||||
| Address2: | |||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750612226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722563537 | ||||||||
| FaxNumber: | 9722557916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2005 | ||||||||
| LastUpdateDate: | 04/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | L2959 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207RH0003X | L2959 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 150452402 | 05 | TX | MEDICAID | 150452407 | 05 | TX | MEDICAID | 150452408 | 05 | TX | MEDICAID |