1417033267 NPI number — BHASKER RAO KOPPULA M.D

Table of content: BHASKER RAO KOPPULA M.D (NPI 1417033267)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417033267 NPI number — BHASKER RAO KOPPULA M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOPPULA
Provider First Name:
BHASKER RAO
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417033267
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
DEPARTMENT OF RADIOLOGY UNIVERSITY OF UTAH
Provider Second Line Business Mailing Address:
30 NORTH 1900 EAST, #1A071
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84132-2140
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-581-7553
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4201 W MEDICAL CENTER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCHENRY
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60050-8409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-334-5566
Provider Business Practice Location Address Fax Number:
815-759-4008
Provider Enumeration Date:
10/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  036166661 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207U00000X , with the licence number: 7682213-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: MD60120325 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 7682213-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 339350 . This is a "INTERNAL ID-MOTOR VEHICLE ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8443277 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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