Healthcare Provider Details

I. General information

NPI: 1427973288
Provider Name (Legal Business Name): MADHAVA SASANK BOPPANA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 PAMPLICO HWY
FLORENCE SC
29505-6019
US

IV. Provider business mailing address

2368 FREEDOM BLVD APT B7
FLORENCE SC
29505-6187
US

V. Phone/Fax

Practice location:
  • Phone: 843-674-2629
  • Fax:
Mailing address:
  • Phone: 843-610-0166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: