Basic Information
| Provider Information | |||||||||
| NPI: | 1649442302 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HALAPPANAVAR | ||||||||
| FirstName: | MONICA | ||||||||
| MiddleName: | MUDUKANNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 W MUHAMMAD ALI BLVD | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025898600 | ||||||||
| FaxNumber: | 5025898771 | ||||||||
| Practice Location | |||||||||
| Address1: | 708 MAGAZINE ST | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402032043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025898600 | ||||||||
| FaxNumber: | 5025898771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2008 | ||||||||
| LastUpdateDate: | 03/06/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2084P0800X | 44982 | KY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 7100145020 | 05 | KY | MEDICAID |