Healthcare Provider Details

I. General information

NPI: 1790742005
Provider Name (Legal Business Name): SUDHARAM IDUPUGANTI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 09/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

585 BAY RIDGE PKWY
BROOKLYN NY
11209-3309
US

IV. Provider business mailing address

585 BAY RIDGE PKWY
BROOKLYN NY
11209-3309
US

V. Phone/Fax

Practice location:
  • Phone: 718-921-1001
  • Fax: 718-921-1001
Mailing address:
  • Phone: 718-921-1001
  • Fax: 718-921-1001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number138851
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: