Basic Information
| Provider Information | |||||||||
| NPI: | 1396090551 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PUPPALA | ||||||||
| FirstName: | DHEERAJ | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6069 | ||||||||
| Address2: | |||||||||
| City: | WEST COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291716069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8039367372 | ||||||||
| FaxNumber: | 8039364102 | ||||||||
| Practice Location | |||||||||
| Address1: | 2720 SUNSET BLVD | ||||||||
| Address2: | |||||||||
| City: | WEST COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291694810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8039367372 | ||||||||
| FaxNumber: | 8039364102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2012 | ||||||||
| LastUpdateDate: | 02/01/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 125062174 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 51544 | SC | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 51544 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 515446 | 05 | SC | MEDICAID |