Provider Demographics
NPI:1073772455
Name:KODURU, SUDHA (MD)
Entity Type:Individual
Prefix:
First Name:SUDHA
Middle Name:
Last Name:KODURU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MEDICAL PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-9274
Mailing Address - Country:US
Mailing Address - Phone:804-765-5991
Mailing Address - Fax:
Practice Address - Street 1:200 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9274
Practice Address - Country:US
Practice Address - Phone:804-765-5991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-02
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA01012500380207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program