Basic Information
| Provider Information | |||||||||
| NPI: | 1033156328 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOKSHAGUNDAM | ||||||||
| FirstName: | SRI PRAKASH | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 E CHESTNUT ST | ||||||||
| Address2: | STE #310 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402025700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025884600 | ||||||||
| FaxNumber: | 5025895093 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 E CHESTNUT ST | ||||||||
| Address2: | STE #310 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402025700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025884600 | ||||||||
| FaxNumber: | 5025895093 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 03/16/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | 28777 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RE0101X | 01046741A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 200058880 | 05 | IN | MEDICAID | 64287774 | 05 | KY | MEDICAID |