Basic Information
| Provider Information | |||||||||
| NPI: | 1942260468 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KODALI | ||||||||
| FirstName: | MURALI KRISHNA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2946 E BANNER GATEWAY DR. | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802563223 | ||||||||
| FaxNumber: | 4802564003 | ||||||||
| Practice Location | |||||||||
| Address1: | 625 N 6TH ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024068222 | ||||||||
| FaxNumber: | 6024064500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2006 | ||||||||
| LastUpdateDate: | 04/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 49958 | AZ | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | ME 101276 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0003X | 49958 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 2814072-00 | 05 | FL | MEDICAID | 41726 | 01 | BLUE CROSS BLUE SHIELD | OTHER | 997033219 | 05 | NM | MEDICAID |