Provider Demographics
NPI:1083900039
Name:BODDAPATI, AVINASH (MD)
Entity Type:Individual
Prefix:
First Name:AVINASH
Middle Name:
Last Name:BODDAPATI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 SEAVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-3401
Mailing Address - Country:US
Mailing Address - Phone:718-226-9000
Mailing Address - Fax:
Practice Address - Street 1:18707 HARDY OAK BLVD STE 410
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4791
Practice Address - Country:US
Practice Address - Phone:877-504-8504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2826972084P0800X, 2084P0804X
TXT84922084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0-4365486Medicaid