Healthcare Provider Details

I. General information

NPI: 1750467718
Provider Name (Legal Business Name): DR. RAMA BOPPANA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

242 WEST SHAMROCK STREET
PINEVILLE LA
71360
US

IV. Provider business mailing address

6200 TENNYSON OAKS LN
ALEXANDRIA LA
71301-2758
US

V. Phone/Fax

Practice location:
  • Phone: 318-484-6814
  • Fax:
Mailing address:
  • Phone: 318-484-6814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number12393R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: