Basic Information
| Provider Information | |||||||||
| NPI: | 1295827855 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KATRAGADDA | ||||||||
| FirstName: | SUDHA | ||||||||
| MiddleName: | RANI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1112 | ||||||||
| Address2: | |||||||||
| City: | FAIRMONT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265551112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043660700 | ||||||||
| FaxNumber: | 3043678766 | ||||||||
| Practice Location | |||||||||
| Address1: | 1322 LOCUST AVE | ||||||||
| Address2: | |||||||||
| City: | FAIRMONT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265541436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043660700 | ||||||||
| FaxNumber: | 3043678766 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 04/05/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 14057 | WV | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000020351 | 01 | WV | TRAVELERS | OTHER | 14257 | 01 | WV | HEALTH NET | OTHER | 00844610000 | 05 | WV | MEDICAID |