Healthcare Provider Details

I. General information

NPI: 1023467495
Provider Name (Legal Business Name): SUDHIR KUNCHALA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2016
Last Update Date: 06/27/2025
Certification Date: 06/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8700 BEVERLY BLVD
WEST HOLLYWOOD CA
90048-1804
US

IV. Provider business mailing address

1 CORPORATE DR STE 325
SHELTON CT
06484-6295
US

V. Phone/Fax

Practice location:
  • Phone: 310-423-6500
  • Fax:
Mailing address:
  • Phone: 203-696-6125
  • Fax: 203-337-9731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number70377
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number70377
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License NumberA200905
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: