Provider Demographics
NPI:1417033267
Name:KOPPULA, BHASKER RAO (MD)
Entity Type:Individual
Prefix:
First Name:BHASKER RAO
Middle Name:
Last Name:KOPPULA
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:DEPARTMENT OF RADIOLOGY UNIVERSITY OF UTAH
Mailing Address - Street 2:30 NORTH 1900 EAST, #1A071
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132-2140
Mailing Address - Country:US
Mailing Address - Phone:801-581-7553
Mailing Address - Fax:
Practice Address - Street 1:4201 W MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-8409
Practice Address - Country:US
Practice Address - Phone:815-334-5566
Practice Address - Fax:815-759-4008
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7682213-1205207U00000X, 2085R0202X
IL0361666612085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
339350OtherINTERNAL ID-MOTOR VEHICLE ID
WA8443277Medicaid
WA8443277Medicaid
8857422Medicare ID - Type Unspecified