MEDICARE: MOREEN KOPPULA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician	13454	AZ

General Provider Information

NPI Number	:	1316943194
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOREEN KOPPULA M.D.

Provider Business Mailing Address
First Line	:	PO BOX 160
Second Line	:
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85252-0160
Country	:	US
Telephone Number	:	480-272-8411
Fax Number	:	480-361-1435

Provider Business Practice Location Address
First Line	:	8102 E MCDOWELL RD
Second Line	:	STE 2C
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85257-3809
Country	:	US
Telephone Number	:	480-272-8411
Fax Number	:	480-361-1435

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2005
Last Update Date	:	02/03/2015

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