Basic Information
| Provider Information | |||||||||
| NPI: | 1891780326 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KUDLAPUR | ||||||||
| FirstName: | SHIVAPRAKASH | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KUDLAPUR | ||||||||
| OtherFirstName: | PRAKASH | ||||||||
| OtherMiddleName: | T | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 188 | ||||||||
| Address2: | |||||||||
| City: | CHILLICOTHE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456010188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407734366 | ||||||||
| FaxNumber: | 7407757855 | ||||||||
| Practice Location | |||||||||
| Address1: | 30381 CHIEFTAIN DR | ||||||||
| Address2: | |||||||||
| City: | LOGAN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431389092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403852555 | ||||||||
| FaxNumber: | 7403803750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2005 | ||||||||
| LastUpdateDate: | 11/06/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35065974K | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0965728 | 05 | OH | MEDICAID | 311155352 | 01 | E V BENEFITS | OTHER | 311155352 | 01 | OH | OHIO HEALTH CHOICE | OTHER | 311155352 | 01 | AETNA | OTHER | P00084899 | 01 | RAILROAD MEDICARE | OTHER | 0408409 | 01 | UNITED HEALTHCARE | OTHER | 311155352 | 01 | CIGNA/CONN GENERAL | OTHER | 311155352 | 01 | PPO NEXT | OTHER | 311155352 | 01 | TRICARE | OTHER | 311155352 | 01 | CENTRAL BENEFITS | OTHER | 000000300069 | 01 | OH | ANTHEM | OTHER | 311155352 | 01 | EMERALD HEALTH | OTHER | 311155352 | 01 | GREAT WEST | OTHER |