Healthcare Provider Details

I. General information

NPI: 1346691409
Provider Name (Legal Business Name): ADITYA VIKRAM BODDU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2016
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 HOWARD AVE LOWR LEVEL
NEW HAVEN CT
06519-1369
US

IV. Provider business mailing address

15 YORK ST FL 7
NEW HAVEN CT
06510-3221
US

V. Phone/Fax

Practice location:
  • Phone: 877-925-3637
  • Fax: 877-925-3329
Mailing address:
  • Phone: 312-806-0442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number85538
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: