Provider Demographics
NPI:1376742312
Name:BUDDINENI, JAYA PRAKASH (MD)
Entity Type:Individual
Prefix:
First Name:JAYA
Middle Name:PRAKASH
Last Name:BUDDINENI
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 1:2901 W KINNICKINNIC RIVER PKWY
Mailing Address - Street 2:SUITE 315
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-3677
Mailing Address - Country:US
Mailing Address - Phone:347-387-3555
Mailing Address - Fax:
Practice Address - Street 1:2901 W KINNICKINNIC RIVER PKWY
Practice Address - Street 2:SUITE 315
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3677
Practice Address - Country:US
Practice Address - Phone:347-387-3555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009010646207R00000X
PAMD443321207R00000X
NMMD2021-0858207RC0200X
TXP9053207RC0200X
WI61965207RC0200X
WI61965-20207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100038329Medicaid