Provider Demographics
NPI:1407010754
Name:DAVULURI, BALA KOTESWARA RAO
Entity type:Individual
Prefix:
First Name:BALA
Middle Name:KOTESWARA RAO
Last Name:DAVULURI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:N/A
Other - Middle Name:N/A
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-2111
Mailing Address - Fax:
Practice Address - Street 1:2354 WEST BOULVARD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-6069
Practice Address - Country:US
Practice Address - Phone:765-457-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN525752084N0400X
WI62281-0202084N0400X
390200000X
IN01084760A2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1407010754Medicaid