Basic Information
| Provider Information | |||||||||
| NPI: | 1417033267 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOPPULA | ||||||||
| FirstName: | BHASKER RAO | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPARTMENT OF RADIOLOGY UNIVERSITY OF UTAH | ||||||||
| Address2: | 30 NORTH 1900 EAST, #1A071 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841322140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015817553 | ||||||||
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| Practice Location | |||||||||
| Address1: | DEPARTMENT OF RADIOLOGY UNIVERSITY OF UTAH | ||||||||
| Address2: | 30 NORTH 1900 EAST, #1A071 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841322140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015817553 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 11/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 7682213-1205 | UT | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 207U00000X | 7682213-1205 | UT | Y | Allopathic & Osteopathic Physicians | Nuclear Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8443277 | 05 | WA | MEDICAID | 339350 | 01 | INTERNAL ID-MOTOR VEHICLE ID | OTHER |