1275620650 NPI number — SMITHA AYODHYARAM GUBBI MD

Table of content: SMITHA AYODHYARAM GUBBI MD (NPI 1275620650)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275620650 NPI number — SMITHA AYODHYARAM GUBBI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUBBI
Provider First Name:
SMITHA
Provider Middle Name:
AYODHYARAM
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275620650
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 416457
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02241-6457
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 UNION AVE
Provider Second Line Business Practice Location Address:
BRIDGEWATER INTERNAL MEDICINE SUITE E
Provider Business Practice Location Address City Name:
BRIDGEWATER
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-685-1818
Provider Business Practice Location Address Fax Number:
908-685-8225
Provider Enumeration Date:
10/06/2006

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: 207Q00000X , with the licence number:  25MA07648800 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0025003 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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