Provider Demographics
NPI:1205934023
Name:KUPPUSWAMY, BAIRAVA S (MD)
Entity type:Individual
Prefix:
First Name:BAIRAVA
Middle Name:S
Last Name:KUPPUSWAMY
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 1:602, DIVISION STREET
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-5652
Mailing Address - Country:US
Mailing Address - Phone:304-865-5151
Mailing Address - Fax:304-485-3251
Practice Address - Street 1:602 DIVISION ST
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-5656
Practice Address - Country:US
Practice Address - Phone:304-865-5151
Practice Address - Fax:304-485-3251
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22064207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810004637Medicaid
WVKU4172891Medicare ID - Type Unspecified
WV3810004637Medicaid
WV1857BMedicare PIN