Provider Demographics
NPI:1053477372
Name:KONKIMALLA, SRIDEVI (MD)
Entity type:Individual
Prefix:
First Name:SRIDEVI
Middle Name:
Last Name:KONKIMALLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 61160
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78466-1160
Mailing Address - Country:US
Mailing Address - Phone:361-884-2904
Mailing Address - Fax:361-857-0572
Practice Address - Street 1:3765 S ALAMEDA ST STE 304
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-1671
Practice Address - Country:US
Practice Address - Phone:361-884-2904
Practice Address - Fax:361-884-2919
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT187482207R00000X
SD7846207RN0300X
TXR3894207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6006350Medicaid
TXR3894OtherTEXAS MEDICAL BOARD
SD6006350Medicaid