Basic Information
| Provider Information | |||||||||
| NPI: | 1871511741 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MADUPUR | ||||||||
| FirstName: | MUKESH | ||||||||
| MiddleName: | KUMAR | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2754 SOLUTION CTR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606772007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064086200 | ||||||||
| FaxNumber: | 6064084775 | ||||||||
| Practice Location | |||||||||
| Address1: | 2201 LEXINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411012843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064087000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 09/22/2015 | ||||||||
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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 | 2085R0202X | 38916 | KY | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 2674422 | 05 | OH | MEDICAID | 3810006434 | 05 | WV | MEDICAID | 64092620 | 05 | KY | MEDICAID |