Provider Demographics
NPI:1043516735
Name:CHARLA, PRADEEPKUMAR (MD, MS)
Entity Type:Individual
Prefix:DR
First Name:PRADEEPKUMAR
Middle Name:
Last Name:CHARLA
Suffix:
Gender:M
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 ELMWOOD AVE BOX 635
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:585-275-6108
Mailing Address - Fax:
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-0001
Practice Address - Country:US
Practice Address - Phone:585-275-6108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-28
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY316270207RA0002X, 2080P0202X
OH35.133440207RC0000X, 2080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Multi-Specialty
No207RA0002XAllopathic & Osteopathic PhysiciansInternal MedicineAdult Congenital Heart DiseaseGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty