Basic Information
| Provider Information | |||||||||
| NPI: | 1942486568 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIRYALA | ||||||||
| FirstName: | REKHA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KALAKUNTHA | ||||||||
| OtherFirstName: | REKHA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1018 BROAD STREET | ||||||||
| Address2: | SUITE 8 | ||||||||
| City: | BLOOMFIELD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070032884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9733384900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1018 BROAD STREET | ||||||||
| Address2: | SUITE 8 | ||||||||
| City: | BLOOMFIELD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070032884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9733384900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2008 | ||||||||
| LastUpdateDate: | 12/22/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 25MA08463200 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0235067 | 05 | NJ | MEDICAID |