Provider Demographics
NPI:1235171968
Name:BANKULLA, PRADEEP R (MD)
Entity Type:Individual
Prefix:
First Name:PRADEEP
Middle Name:R
Last Name:BANKULLA
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 782743
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-2743
Mailing Address - Country:US
Mailing Address - Phone:602-910-6887
Mailing Address - Fax:215-612-5077
Practice Address - Street 1:4900 FRANKFORD AVE
Practice Address - Street 2:ATTN: RADIOLOGY
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-2618
Practice Address - Country:US
Practice Address - Phone:602-910-6887
Practice Address - Fax:215-612-5077
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4319332085R0204X, 2085R0202X
NJ25MA082987002085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology