Provider Demographics
NPI:1366402505
Name:PATRA, KUNAL K (MD)
Entity type:Individual
Prefix:
First Name:KUNAL
Middle Name:K
Last Name:PATRA
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:PO BOX 5427
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51102-5427
Mailing Address - Country:US
Mailing Address - Phone:712-274-6729
Mailing Address - Fax:712-274-6744
Practice Address - Street 1:3549 SOUTHERN HILLS DR
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51106-4736
Practice Address - Country:US
Practice Address - Phone:712-274-6729
Practice Address - Fax:712-274-6744
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA352032084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0430702Medicaid
P00150357OtherMEDICARE ID UNSPECIFIED
P00150357OtherMEDICARE ID UNSPECIFIED
IA0430702Medicaid