Provider Demographics
NPI:1588017305
Name:KOPPULA, MAHESWARA REDDY (MD)
Entity type:Individual
Prefix:
First Name:MAHESWARA
Middle Name:REDDY
Last Name:KOPPULA
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 1:1643 NW 136TH AVE
Mailing Address - Street 2:BL H ST 100 MSC 11607-0002
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2857
Mailing Address - Country:US
Mailing Address - Phone:954-377-2939
Mailing Address - Fax:
Practice Address - Street 1:651 DUNLOP LN
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040
Practice Address - Country:US
Practice Address - Phone:931-502-5090
Practice Address - Fax:931-502-5081
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-16
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH028172207R00000X
PAMD477801207R00000X
DEDR-0026718207R00000X
390200000X
TN58980207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100626230Medicaid