Provider Demographics
NPI:1558567735
Name:KURUDIYARA, PREETHA Y (MD)
Entity Type:Individual
Prefix:
First Name:PREETHA
Middle Name:Y
Last Name:KURUDIYARA
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 8003
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54912-8003
Mailing Address - Country:US
Mailing Address - Phone:920-996-5900
Mailing Address - Fax:920-738-5787
Practice Address - Street 1:2701 E ENTERPRISE AVE
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-7729
Practice Address - Country:US
Practice Address - Phone:920-954-2551
Practice Address - Fax:920-954-2554
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49289208000000X, 2080A0000X, 207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1558567735Medicaid