Provider Demographics
NPI:1194995357
Name:JAGARLAMUDI, KUPPUSWAMY (MD)
Entity type:Individual
Prefix:
First Name:KUPPUSWAMY
Middle Name:
Last Name:JAGARLAMUDI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 HEALTH CENTER DR
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-9253
Mailing Address - Country:US
Mailing Address - Phone:217-258-2250
Mailing Address - Fax:217-258-2249
Practice Address - Street 1:1000 HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-9253
Practice Address - Country:US
Practice Address - Phone:217-258-2250
Practice Address - Fax:217-258-2249
Is Sole Proprietor?:No
Enumeration Date:2008-03-04
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-128607207RH0003X
NY247809207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine