Basic Information
| Provider Information | |||||||||
| NPI: | 1851577787 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KUPPALA | ||||||||
| FirstName: | VENKATA | ||||||||
| MiddleName: | S. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3702 NEW VISION DR | ||||||||
| Address2: | STE B | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602668210 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4199 GATEWAY BLVD | ||||||||
| Address2: | |||||||||
| City: | NEWBURGH | ||||||||
| State: | IN | ||||||||
| PostalCode: | 476308940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128424200 | ||||||||
| FaxNumber: | 8126023174 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2008 | ||||||||
| LastUpdateDate: | 06/28/2019 | ||||||||
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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 | 208000000X | 35.090012 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 01068809A | IN | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080N0001X | 01068809A | IN | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01068809A | 01 | IN | IN LICENSE | OTHER |