Provider Demographics
NPI:1437157146
Name:KUDALKAR, DEEPA P (MD)
Entity Type:Individual
Prefix:
First Name:DEEPA
Middle Name:P
Last Name:KUDALKAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DEEPA
Other - Middle Name:J
Other - Last Name:BALAKRISHNAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:237 WILLIAM HOWARD TAFT, PHYSICIAN DIVISION
Mailing Address - Street 2:2ND FL, CBO2-3, ATTN: CREDENTIALING
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-2906
Mailing Address - Country:US
Mailing Address - Phone:513-263-8571
Mailing Address - Fax:513-366-4480
Practice Address - Street 1:2355 NORWOOD AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45212-2750
Practice Address - Country:US
Practice Address - Phone:513-351-0800
Practice Address - Fax:513-351-3970
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11197207R00000X
OH35-092770207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH699435OtherBUCKEYE - MEDICARE
OH760174OtherBUCKEYE - MEDICAID
OHH110400OtherMEDICARE
OH2980181OtherMEDICAID
OH737691OtherANTHEM
OHP01107611OtherRAILROAD MEDICARE
OH7708721OtherAETNA
KY7100287660OtherMEDICAID