Healthcare Provider Details

I. General information

NPI: 1073772455
Provider Name (Legal Business Name): SUDHA KODURU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2008
Last Update Date: 04/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MEDICAL PARK BLVD
PETERSBURG VA
23805-9274
US

IV. Provider business mailing address

200 MEDICAL PARK BLVD
PETERSBURG VA
23805-9274
US

V. Phone/Fax

Practice location:
  • Phone: 804-765-5991
  • Fax:
Mailing address:
  • Phone: 804-765-5991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01012500380
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: