Basic Information
| Provider Information | |||||||||
| NPI: | 1437157146 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KUDALKAR | ||||||||
| FirstName: | DEEPA | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BALAKRISHNAN | ||||||||
| OtherFirstName: | DEEPA | ||||||||
| OtherMiddleName: | J. | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 237 WILLIAM HOWARD TAFT, PHYSICIAN DIVISION | ||||||||
| Address2: | 2ND FL, CBO2-3, ATTN: CREDENTIALING | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452192906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132638571 | ||||||||
| FaxNumber: | 5133664480 | ||||||||
| Practice Location | |||||||||
| Address1: | 2355 NORWOOD AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452122750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5133510800 | ||||||||
| FaxNumber: | 5133513970 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 10/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 11197 | NV | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RR0500X | 35-092770 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
| ID | Type | State | Issuer | Description | 699435 | 01 | OH | BUCKEYE - MEDICARE | OTHER | 760174 | 01 | OH | BUCKEYE - MEDICAID | OTHER | H110400 | 01 | OH | MEDICARE | OTHER | 2980181 | 01 | OH | MEDICAID | OTHER | 737691 | 01 | OH | ANTHEM | OTHER | P01107611 | 01 | OH | RAILROAD MEDICARE | OTHER | 7708721 | 01 | OH | AETNA | OTHER | 7100287660 | 01 | KY | MEDICAID | OTHER |