Provider Demographics
NPI:1750308235
Name:RUDRAPPA, KUSUM (MD)
Entity Type:Individual
Prefix:MS
First Name:KUSUM
Middle Name:
Last Name:RUDRAPPA
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 1:4341 REDWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6427
Mailing Address - Country:US
Mailing Address - Phone:213-577-1119
Mailing Address - Fax:213-577-1119
Practice Address - Street 1:421 E ANGELENO AVE
Practice Address - Street 2:STE: 206B
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91501-2286
Practice Address - Country:US
Practice Address - Phone:310-984-6949
Practice Address - Fax:310-984-6949
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37070208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF01866Medicare UPIN