Provider Demographics
NPI:1740237189
Name:JAKKULA, MRUDULA (PHYSICIAN,MB,BS)
Entity Type:Individual
Prefix:
First Name:MRUDULA
Middle Name:
Last Name:JAKKULA
Suffix:
Gender:F
Credentials:PHYSICIAN,MB,BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2610 CENTRAL AVE NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-2911
Mailing Address - Country:US
Mailing Address - Phone:612-781-6816
Mailing Address - Fax:612-781-3837
Practice Address - Street 1:2610 CENTRAL AVE NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55418-2911
Practice Address - Country:US
Practice Address - Phone:612-781-6816
Practice Address - Fax:612-781-3837
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN38533207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNG33530Medicare UPIN