Provider Demographics
NPI:1750341392
Name:BODALA, DURGA R (MD)
Entity type:Individual
Prefix:
First Name:DURGA
Middle Name:R
Last Name:BODALA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:DURGA
Other - Middle Name:R
Other - Last Name:PUDHOTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4013 ROUTE 9 N STE 1N
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07731-3307
Mailing Address - Country:US
Mailing Address - Phone:732-905-5255
Mailing Address - Fax:732-905-5266
Practice Address - Street 1:4013 ROUTE 9 N STE 1N
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:NJ
Practice Address - Zip Code:07731-3307
Practice Address - Country:US
Practice Address - Phone:732-905-5255
Practice Address - Fax:732-905-5266
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA079633207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0096474Medicaid
NJ0096474Medicaid
NJ095676XPFMedicare PIN
NJI44841Medicare UPIN