Healthcare Provider Details

I. General information

NPI: 1528261617
Provider Name (Legal Business Name): SUDHEER REDDY KOYAGURA M.D., MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 06/28/2021
Certification Date: 06/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W MAPLE AVE SUITE 704
SPRINGDALE AR
72764-5335
US

IV. Provider business mailing address

601 W MAPLE AVE SUITE 704
SPRINGDALE AR
72764-5335
US

V. Phone/Fax

Practice location:
  • Phone: 479-757-3717
  • Fax:
Mailing address:
  • Phone: 479-757-3717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE6603
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberE6603
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number31671
License Number StateOK
# 4
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberE6603
License Number StateAR
# 5
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberE6602
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: