Provider Demographics
NPI:1346395852
Name:ANCHA, SUDHAKAR (MD)
Entity Type:Individual
Prefix:DR
First Name:SUDHAKAR
Middle Name:
Last Name:ANCHA
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 1:2216 E 32ND ST
Mailing Address - Street 2:STE 103
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-3016
Mailing Address - Country:US
Mailing Address - Phone:417-623-5250
Mailing Address - Fax:417-623-8302
Practice Address - Street 1:2216 E 32ND ST
Practice Address - Street 2:STE 103
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3016
Practice Address - Country:US
Practice Address - Phone:417-623-5250
Practice Address - Fax:417-623-8302
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005009627207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207197401Medicaid
MOG44970Medicare UPIN
MO000093116Medicare ID - Type Unspecified