Provider Demographics
NPI:1174532386
Name:KODITYAL, ANJAIAH (MD)
Entity type:Individual
Prefix:
First Name:ANJAIAH
Middle Name:
Last Name:KODITYAL
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 1:420 E 6TH ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-4529
Mailing Address - Country:US
Mailing Address - Phone:432-337-0555
Mailing Address - Fax:432-337-0558
Practice Address - Street 1:420 E 6TH ST
Practice Address - Street 2:SUITE 205
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4529
Practice Address - Country:US
Practice Address - Phone:432-337-0555
Practice Address - Fax:432-337-0558
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH8708207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
116990100OtherFIRST CARE
290005045OtherRAILROAD MEDICARE
TXOOJ89ZOtherBLUE CROSS BLUE SHIELD
TX5241453OtherAETNA
TX131791905Medicaid
C78404Medicare UPIN
OOJ89ZMedicare ID - Type Unspecified