Provider Demographics
NPI:1770641763
Name:KOPPULA, SAMYUKTA (MD)
Entity Type:Individual
Prefix:
First Name:SAMYUKTA
Middle Name:
Last Name:KOPPULA
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 1:6857 KINGERY HWY
Mailing Address - Street 2:
Mailing Address - City:WILLOWBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60527-5114
Mailing Address - Country:US
Mailing Address - Phone:630-323-8800
Mailing Address - Fax:630-850-9797
Practice Address - Street 1:6857 KINGERY HWY
Practice Address - Street 2:
Practice Address - City:WILLOWBROOK
Practice Address - State:IL
Practice Address - Zip Code:60527-5114
Practice Address - Country:US
Practice Address - Phone:630-323-8800
Practice Address - Fax:630-850-9797
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL00303660782441207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL003-036-078244-1OtherSTATE OF IL LICENCE
IL2233164OtherBCBS OF ILLINOIS
ILK37017Medicare PIN
ILP00650478Medicare PIN