Chandra Kumar Mallic Kodavanti, MD

Primary specialty

Critical Care Medicine (Internal Medicine) PhysicianTaxonomy code 207RC0200X

License

MD.46417 Issued in AL

Practice address

1108 Ross Clark Cir
Dothan, AL 36301-3022

Phone

(334) 703-8836

Fax

(334) 712-3512

NPI assigned

Jul 5, 2017

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Medicare fee-for-service enrollment

Enrolled in AL

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Specialty

Critical Care (Intensivists)

Education

Other, 2011

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Houston County Healthcare AuthorityGroup PAC ID 9436062296, 256 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• Southeast Health Medical Center Hospital, Dothan, AL, CCN 010001

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Houston County Healthcare Authority

  • Internal Medicine Physician
  • Enterprise, AL
  • NPI 1619026606
  Medicare reassignment Care Compare group NPD
• Houston County Healthcare Authority

  • Internal Medicine Physician
  • Dothan, AL
  • NPI 1538597349
  NPD

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• Houston County Healthcare Authority

  • General Acute Care Hospital
  • Dothan, AL
  • NPI 1164403861
  Care Compare affiliation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1499212800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1690243200000",
    "number": "1093236580",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1928",
            "city": "DOTHAN",
            "state": "AL",
            "postal_code": "363021928"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1108 ROSS CLARK CIR",
            "city": "DOTHAN",
            "state": "AL",
            "postal_code": "363013022",
            "telephone_number": "334-703-8836",
            "fax_number": "334-712-3512"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "Msc 10-5550 1 University Of New Mexico",
            "address_purpose": "LOCATION",
            "city": "Albuquerque",
            "state": "NM",
            "postal_code": "871310001",
            "country_code": "US",
            "telephone_number": "505-272-4751",
            "fax_number": "505-272-8700",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "701 W 5th St",
            "address_purpose": "LOCATION",
            "city": "Odessa",
            "state": "TX",
            "postal_code": "797634206",
            "country_code": "US",
            "telephone_number": "432-703-5375",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "KODAVANTI",
        "first_name": "CHANDRA KUMAR MALLIC",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2017-07-05",
        "last_updated": "2023-07-25",
        "certification_date": "2023-07-25",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": "NM",
            "license": "RS2020-0463",
            "primary": false
        },
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": "TX",
            "license": "BP10060414",
            "primary": false
        },
        {
            "code": "207RC0200X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Critical Care Medicine",
            "state": "AL",
            "license": "MD.46417",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Robert Samuel Kline, PSY.D.
• Diane Klivington, DO, MS
• KND Development 59 LLC
• Tera R. Knighton, C.P.N.P.
• Mayre Katherine Knox, CRNP
• Joan Lee Kogelschatz, PHD
• Richard Woodland Kohl Jr., LPC
• Krystal Sims Kornegay, CRNP
• Beverly Kosik, CRNP
• Chelsey Wilson Kosik, CRNP

• Critical Care Medicine (Internal Medicine) Physician in Dothan, AL
• Providers in Dothan, AL by specialty
• Critical Care Medicine (Internal Medicine) Physician in Alabama

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 25, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.