Provider Demographics
NPI:1942208905
Name:BHOOPALAM, PRAKASH S (MD)
Entity Type:Individual
Prefix:DR
First Name:PRAKASH
Middle Name:S
Last Name:BHOOPALAM
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 1:6800 W SAINT ANDREWS AVE
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47396-9333
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2525 W UNIVERSITY AVE
Practice Address - Street 2:SUITE 404
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303
Practice Address - Country:US
Practice Address - Phone:765-231-9494
Practice Address - Fax:765-587-4456
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040631A208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100362560Medicaid