Provider Demographics
NPI:1992797690
Name:BOPPANA, SUSHMA (MD)
Entity type:Individual
Prefix:DR
First Name:SUSHMA
Middle Name:
Last Name:BOPPANA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 GRIGGS TER
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-4702
Mailing Address - Country:US
Mailing Address - Phone:631-327-4841
Mailing Address - Fax:
Practice Address - Street 1:13 GRIGGS TER
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-4702
Practice Address - Country:US
Practice Address - Phone:631-327-4841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY199972207ZP0102X
MA236771207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY51R002Medicare PIN
NY51R003Medicare PIN
NYG68748Medicare UPIN
NYD68748Medicare PIN
NY51R001Medicare PIN
NY51R321Medicare PIN