Provider Demographics
NPI:1821346263
Name:KUPPANNAGARI, JYOTSNA (MD)
Entity Type:Individual
Prefix:DR
First Name:JYOTSNA
Middle Name:
Last Name:KUPPANNAGARI
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 1:303 S HIGHWAY 78 STE 106
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-3915
Mailing Address - Country:US
Mailing Address - Phone:361-944-1190
Mailing Address - Fax:972-429-5410
Practice Address - Street 1:303 S HIGHWAY 78 STE 106
Practice Address - Street 2:
Practice Address - City:WYLIE
Practice Address - State:TX
Practice Address - Zip Code:75098-3915
Practice Address - Country:US
Practice Address - Phone:940-381-1501
Practice Address - Fax:972-801-9015
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-15
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ2680208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX349806501Medicaid