Provider Demographics
NPI:1194379198
Name:BOPPANA, LEELA KRISHNA TEJA (MD)
Entity Type:Individual
Prefix:
First Name:LEELA KRISHNA TEJA
Middle Name:
Last Name:BOPPANA
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 1:555 WEST 8TH STREET, P18
Mailing Address - Street 2:4TH FLOOR, PAVILION NORTH
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209
Mailing Address - Country:US
Mailing Address - Phone:904-244-1658
Mailing Address - Fax:
Practice Address - Street 1:555 W 8TH ST FL P184
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6552
Practice Address - Country:US
Practice Address - Phone:904-244-1658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-29
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLTRN34344390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program