Provider Demographics
NPI:1790742005
Name:IDUPUGANTI, SUDHARAM (MD)
Entity Type:Individual
Prefix:DR
First Name:SUDHARAM
Middle Name:
Last Name:IDUPUGANTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 BAY RIDGE PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-3309
Mailing Address - Country:US
Mailing Address - Phone:718-921-1001
Mailing Address - Fax:718-921-1001
Practice Address - Street 1:585 BAY RIDGE PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-3309
Practice Address - Country:US
Practice Address - Phone:718-921-1001
Practice Address - Fax:718-921-1001
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-28
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1388512084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00435676Medicaid
NY23A231Medicare ID - Type Unspecified
NY00435676Medicaid