MEDICARE: DR. SUDHARAM IDUPUGANTI MD

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	2084P0800X	Psychiatry Physician	138851	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790742005
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUDHARAM IDUPUGANTI MD

Provider Business Mailing Address
First Line	:	585 BAY RIDGE PKWY
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11209-3309
Country	:	US
Telephone Number	:	718-921-1001
Fax Number	:	718-921-1001

Provider Business Practice Location Address
First Line	:	585 BAY RIDGE PKWY
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11209-3309
Country	:	US
Telephone Number	:	718-921-1001
Fax Number	:	718-921-1001

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

Provider Enumeration Date	:	04/28/2006
Last Update Date	:	09/30/2011

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