Provider Demographics
NPI:1679093694
Name:METHUKUPALLY, ABHISHEK REDDY
Entity Type:Individual
Prefix:
First Name:ABHISHEK
Middle Name:REDDY
Last Name:METHUKUPALLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 PERKINS RD APT 2244
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-5309
Mailing Address - Country:US
Mailing Address - Phone:929-288-1858
Mailing Address - Fax:
Practice Address - Street 1:8585 PICARDY AVE STE A
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3748
Practice Address - Country:US
Practice Address - Phone:225-381-6762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-21
Last Update Date:2017-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA306022390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty