Provider Demographics
NPI:1376504019
Name:OMPRAKASH, KUDUVALLI (MD)
Entity Type:Individual
Prefix:
First Name:KUDUVALLI
Middle Name:
Last Name:OMPRAKASH
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 1:235 PORT RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10302-1701
Mailing Address - Country:US
Mailing Address - Phone:718-924-2254
Mailing Address - Fax:718-442-0189
Practice Address - Street 1:235 PORT RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10302-1701
Practice Address - Country:US
Practice Address - Phone:718-924-2254
Practice Address - Fax:718-442-0189
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY146561207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00810206Medicaid
B79704Medicare UPIN
86A541Medicare ID - Type Unspecified