Provider Demographics
NPI:1730163494
Name:KODUKULA, DIPA (OD)
Entity type:Individual
Prefix:
First Name:DIPA
Middle Name:
Last Name:KODUKULA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:DIPA
Other - Middle Name:
Other - Last Name:MODY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:3419 EL SALIDO PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-5639
Mailing Address - Country:US
Mailing Address - Phone:512-918-3937
Mailing Address - Fax:512-918-2028
Practice Address - Street 1:3419 EL SALIDO PKWY
Practice Address - Street 2:STE 100
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-5639
Practice Address - Country:US
Practice Address - Phone:512-918-3937
Practice Address - Fax:512-918-2028
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6753TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX6753TGOtherOPTOMETRY
MM1311214OtherDEA LICENSE
8L24655Medicare PIN