Basic Information
| Provider Information | |||||||||
| NPI: | 1407010754 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVULURI | ||||||||
| FirstName: | BALA | ||||||||
| MiddleName: | KOTESWARA RAO | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | N/A | ||||||||
| OtherFirstName: | N/A | ||||||||
| OtherMiddleName: | N/A | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 844658 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752844658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547242111 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2354 WEST BOULVARD | ||||||||
| Address2: | |||||||||
| City: | KOKOMO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469026069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654574800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2008 | ||||||||
| LastUpdateDate: | 04/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 52575 | MN | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 62281-020 | WI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2084N0400X | 01084760A | IN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 1407010754 | 05 | MN | MEDICAID |