Basic Information
| Provider Information | |||||||||
| NPI: | 1790057941 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOPPAKA | ||||||||
| FirstName: | SUDHA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3411 WAYNE AVE | ||||||||
| Address2: | ENDOCRINOLOGY SUIT G, 1ST FLOOR | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104672509 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3411 WAYNE AVE | ||||||||
| Address2: | ENDOCRINOLOGY SUIT G, 1ST FLOOR | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104672509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189202017 | ||||||||
| FaxNumber: | 7189205202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2012 | ||||||||
| LastUpdateDate: | 02/03/2012 | ||||||||
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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 | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.