Provider Demographics
NPI:1891780326
Name:KUDLAPUR, SHIVAPRAKASH T (MD)
Entity Type:Individual
Prefix:
First Name:SHIVAPRAKASH
Middle Name:T
Last Name:KUDLAPUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PRAKASH
Other - Middle Name:T
Other - Last Name:KUDLAPUR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-0188
Mailing Address - Country:US
Mailing Address - Phone:740-773-4366
Mailing Address - Fax:740-775-7855
Practice Address - Street 1:30381 CHIEFTAIN DR
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:OH
Practice Address - Zip Code:43138-9092
Practice Address - Country:US
Practice Address - Phone:740-385-2555
Practice Address - Fax:740-380-3750
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35065974K207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0965728Medicaid
311155352OtherE V BENEFITS
OH311155352OtherOHIO HEALTH CHOICE
311155352OtherAETNA
P00084899OtherRAILROAD MEDICARE
0408409OtherUNITED HEALTHCARE
311155352OtherCIGNA/CONN GENERAL
311155352OtherPPO NEXT
311155352OtherTRICARE
311155352OtherCENTRAL BENEFITS
OH000000300069OtherANTHEM
311155352OtherEMERALD HEALTH
311155352OtherGREAT WEST
311155352OtherPPO NEXT
311155352OtherGREAT WEST