Provider Demographics
NPI:1376632638
Name:PUPPALA, SHILPA (MD)
Entity Type:Individual
Prefix:
First Name:SHILPA
Middle Name:
Last Name:PUPPALA
Suffix:
Gender:F
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 31455
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-8455
Mailing Address - Country:US
Mailing Address - Phone:925-296-7150
Mailing Address - Fax:925-296-7171
Practice Address - Street 1:836 W WELLINGTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657
Practice Address - Country:US
Practice Address - Phone:773-296-7820
Practice Address - Fax:773-296-7821
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361130362085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036113036Medicaid
IL211655Medicare ID - Type Unspecified
IL036113036Medicaid