Healthcare Provider Details

I. General information

NPI: 1376632638
Provider Name (Legal Business Name): SHILPA PUPPALA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 09/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 W WELLINGTON AVE
CHICAGO IL
60657
US

IV. Provider business mailing address

PO BOX 31455
WALNUT CREEK CA
94598-8455
US

V. Phone/Fax

Practice location:
  • Phone: 773-296-7820
  • Fax: 773-296-7821
Mailing address:
  • Phone: 925-296-7150
  • Fax: 925-296-7171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036113036
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: