Basic Information
| Provider Information | |||||||||
| NPI: | 1942208905 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BHOOPALAM | ||||||||
| FirstName: | PRAKASH | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6800 W SAINT ANDREWS AVE | ||||||||
| Address2: | |||||||||
| City: | YORKTOWN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473969333 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2525 W UNIVERSITY AVE | ||||||||
| Address2: | SUITE 404 | ||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652319494 | ||||||||
| FaxNumber: | 7655874456 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2005 | ||||||||
| LastUpdateDate: | 11/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 01040631A | IN | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080N0001X | 01040631A | IN | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100362560 | 05 | IN | MEDICAID |