Provider Demographics
NPI:1871567214
Name:KONDRAGUNTA, BUTCHAIAH (MD)
Entity type:Individual
Prefix:DR
First Name:BUTCHAIAH
Middle Name:
Last Name:KONDRAGUNTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 MEDICAL PARK BLVD STE G
Mailing Address - Street 2:SUITE # G
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-9283
Mailing Address - Country:US
Mailing Address - Phone:804-722-3100
Mailing Address - Fax:804-722-3120
Practice Address - Street 1:34 MEDICAL PARK BLVD STE G
Practice Address - Street 2:SUITE # G
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9283
Practice Address - Country:US
Practice Address - Phone:804-722-3100
Practice Address - Fax:804-722-3120
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101223780207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005847141Medicaid
VA337600OtherBCBS
VA541989200OtherMAILHANDLERS
VA005839777Medicaid
VA1316020399OtherHEMATOLOGY/ONCOLOGY
VA258076OtherBCBS
VA7608086OtherAETNA
VA26641OtherCIGNA
VAG44642Medicare UPIN
VA005847141Medicaid