Healthcare Provider Details

I. General information

NPI: 1700033032
Provider Name (Legal Business Name): MADAN MOHAN REDDY KOPPOLU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2008
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 JACKSON ST
MONROE LA
71201-7407
US

IV. Provider business mailing address

8312 MISTY CREEK DR
GERMANTOWN TN
38138-7604
US

V. Phone/Fax

Practice location:
  • Phone: 318-966-4000
  • Fax:
Mailing address:
  • Phone: 520-906-7591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD204817
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number51854
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: