Provider Demographics
NPI:1679745533
Name:MEERA S. BOPPANA,MD.PC
Entity Type:Organization
Organization Name:MEERA S. BOPPANA,MD.PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MEERA
Authorized Official - Middle Name:S
Authorized Official - Last Name:BOPPANA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-441-0660
Mailing Address - Street 1:150-38 UNION TURNPIKE
Mailing Address - Street 2:#12E
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-2702
Mailing Address - Country:US
Mailing Address - Phone:718-441-0660
Mailing Address - Fax:718-847-1538
Practice Address - Street 1:10415 101ST AVE
Practice Address - Street 2:
Practice Address - City:OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11416-2702
Practice Address - Country:US
Practice Address - Phone:718-441-0660
Practice Address - Fax:718-847-1538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-31
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY175209207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01305908Medicaid
NY01786GMedicare PIN