Basic Information
| Provider Information | |||||||||
| NPI: | 1023114154 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHIVAPRASAD | ||||||||
| FirstName: | HULLUKUNTE | ||||||||
| MiddleName: | BYLAPPA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2001 SCIOTO TRAIL | ||||||||
| Address2: | STE 200 | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403538100 | ||||||||
| FaxNumber: | 7403538908 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 SCIOTO TRAIL | ||||||||
| Address2: | STE 200 | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403538100 | ||||||||
| FaxNumber: | 7403538908 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 05/18/2011 | ||||||||
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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 | 207RC0000X | 35044638S | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 64114994 | 05 | KY | MEDICAID | 0464788 | 05 | OH | MEDICAID |