Provider Demographics
NPI:1114981156
Name:KUKKILLAYA, RADHAKRISHNA (MD)
Entity Type:Individual
Prefix:
First Name:RADHAKRISHNA
Middle Name:
Last Name:KUKKILLAYA
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:PO BOX 58187
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25358-0187
Mailing Address - Country:US
Mailing Address - Phone:304-792-6282
Mailing Address - Fax:304-792-6290
Practice Address - Street 1:38 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-3452
Practice Address - Country:US
Practice Address - Phone:304-792-6282
Practice Address - Fax:304-792-6290
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV18738207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0079677000Medicaid
WVKU7237502Medicare PIN
WV0079677000Medicaid