1346458767 NPI number — DR. BHASKAR GUNDABOLU M.D.

Table of content: DR. BHASKAR GUNDABOLU M.D. (NPI 1346458767)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346458767 NPI number — DR. BHASKAR GUNDABOLU M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUNDABOLU
Provider First Name:
BHASKAR
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1346458767
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2100 W CENTRAL AVE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43606-3834
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-537-5111
Provider Business Mailing Address Fax Number:
419-537-5131

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2100 W CENTRAL AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
TOLEDO
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43606-3834
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-537-5111
Provider Business Practice Location Address Fax Number:
419-537-5131
Provider Enumeration Date:
05/18/2007

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: 207RE0101X , with the licence number:  35088652 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9567063 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 6870 . This is a "PARAMOUNT" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2831243 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 66501560001 . This is a "MEDICAL MUTUAL" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 751132 . This is a "BUCKEYE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000541140 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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