Provider Demographics
NPI:1790866333
Name:KOPPAKA, VENKATARAMA RAO (MD)
Entity Type:Individual
Prefix:DR
First Name:VENKATARAMA
Middle Name:RAO
Last Name:KOPPAKA
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 1:151 W 17TH ST APT 2C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-5427
Mailing Address - Country:US
Mailing Address - Phone:347-387-4214
Mailing Address - Fax:
Practice Address - Street 1:151 W 17TH ST APT 2C
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-5427
Practice Address - Country:US
Practice Address - Phone:347-387-4214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101058482207R00000X, 207RP1001X, 207RC0200X
NY248397-1207RP1001X, 207R00000X
NY248397207RP1001X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
008834M84 C03684Medicare ID - Type Unspecified
F35574Medicare UPIN