Provider Demographics
NPI:1356531388
Name:KOPPULA, SIREESHA (MD)
Entity type:Individual
Prefix:
First Name:SIREESHA
Middle Name:
Last Name:KOPPULA
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 BRADBURY DR SE STE 116
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4310
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:UNM HOSPITALS
Practice Address - Street 2:2211 LOMAS BLVD NE
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106
Practice Address - Country:US
Practice Address - Phone:505-272-4281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ37291207R00000X, 207RN0300X
NMMD2020-0102207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ233952Medicaid
AZP00447267OtherRAILROAD MEDICARE
AZP00447267OtherRAILROAD MEDICARE