Basic Information
| Provider Information | |||||||||
| NPI: | 1750905642 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOMMINENI | ||||||||
| FirstName: | SAI KARTHIK | ||||||||
| MiddleName: | |||||||||
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| Credential: | MBBS | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 325 N STATE OF FRANKLIN ROAD | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376046056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234396283 | ||||||||
| FaxNumber: | 4234396386 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 N STATE OF FRANKLIN ROAD | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376046056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234396283 | ||||||||
| FaxNumber: | 4234396386 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2020 | ||||||||
| LastUpdateDate: | 07/25/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 01/18/2022 | ||||||||
| NPIReactivationDate: | 07/25/2022 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.