1487663415 NPI number — KRISHNA R S GUJAVARTY MD

Table of content: KRISHNA R S GUJAVARTY MD (NPI 1487663415)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487663415 NPI number — KRISHNA R S GUJAVARTY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUJAVARTY
Provider First Name:
KRISHNA
Provider Middle Name:
R S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GUJAVARTY
Provider Other First Name:
KRISHNAREDDY
Provider Other Middle Name:
S
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1487663415
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
49 DOLPHIN LANE EAST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COPIAGUE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11726-5415
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-331-0028
Provider Business Mailing Address Fax Number:
631-608-3387

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
49 DOLPHIN LANE EAST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COPIAGUE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11726
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-331-0028
Provider Business Practice Location Address Fax Number:
631-608-3387
Provider Enumeration Date:
08/07/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  141407 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00604040 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".