Provider Demographics
NPI:1114232428
Name:KODURU, SOBHA R (MD)
Entity Type:Individual
Prefix:DR
First Name:SOBHA
Middle Name:R
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 1:30 BERGEN STREET
Mailing Address - Street 2:BUILDING 12 ROOM 1205
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07107-3000
Mailing Address - Country:US
Mailing Address - Phone:973-972-0037
Mailing Address - Fax:973-972-0743
Practice Address - Street 1:150 BERGEN ST # UHH-245
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103
Practice Address - Country:US
Practice Address - Phone:973-972-5672
Practice Address - Fax:973-972-0365
Is Sole Proprietor?:No
Enumeration Date:2010-08-11
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ48189207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ845863Medicaid
NJ0595403Medicaid