Provider Demographics
NPI:1265429419
Name:BOPPANA, SURESH B (MD)
Entity type:Individual
Prefix:
First Name:SURESH
Middle Name:B
Last Name:BOPPANA
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 1:703 VOLKER HL
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35294-0001
Mailing Address - Country:US
Mailing Address - Phone:205-934-3795
Mailing Address - Fax:
Practice Address - Street 1:1600 7TH AVE S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-1711
Practice Address - Country:US
Practice Address - Phone:205-939-9587
Practice Address - Fax:205-975-4623
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.15386207P00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009912612Medicaid
AL009930750Medicaid
AL4461381OtherAETNA
AL510-95531OtherBCBS
AL1265429419OtherTRICARE SOUTH
AL000088303Medicaid
AL510-88303OtherBCBS
AL000088303Medicaid