Provider Demographics
NPI:1225420839
Name:KOPPANUR, RADHIKA
Entity Type:Individual
Prefix:
First Name:RADHIKA
Middle Name:
Last Name:KOPPANUR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15200 US-59 SOUTH
Mailing Address - Street 2:360
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77478-4032
Mailing Address - Country:US
Mailing Address - Phone:713-840-5170
Mailing Address - Fax:281-494-2872
Practice Address - Street 1:15200 US-59 S.
Practice Address - Street 2:360
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-4032
Practice Address - Country:US
Practice Address - Phone:713-840-5170
Practice Address - Fax:281-494-2872
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-19
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT06210133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered