Basic Information
| Provider Information | |||||||||
| NPI: | 1265567325 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | UPPU | ||||||||
| FirstName: | KRISHNA | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 E SHERIDAN RD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329013122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217225200 | ||||||||
| FaxNumber: | 3219537510 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 E SHERIDAN RD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329013122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217225200 | ||||||||
| FaxNumber: | 3219537510 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 05/20/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | ME82506 | FL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084P0800X | ME82506 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 263201200 | 05 | FL | MEDICAID |