1497750046 NPI number — DR. PRASAD R. GUDAVALLI MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497750046 NPI number — DR. PRASAD R. GUDAVALLI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUDAVALLI
Provider First Name:
PRASAD
Provider Middle Name:
R.
Provider Name Prefix Text:
DR.
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:
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:
1497750046
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7702 - 16TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11214-1002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-645-2929
Provider Business Mailing Address Fax Number:
718-621-4119

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7702 - 16TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11214-1002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-645-2929
Provider Business Practice Location Address Fax Number:
718-621-4119
Provider Enumeration Date:
06/20/2005

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: 174400000X , with the licence number:  128146 , 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: 00366349 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0046803 . This is a "GROUP HEALTH INC." identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 069508793 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1000016766 . This is a "AFFINITY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 4556190 . This is a "CIGNA HEALTHCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: OXFORD . This is a "P393018" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 069508709 . This is a "OXFORD HEALTH PLAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 07A361 . This is a "BLUE CROSS & BLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 97367 . This is a "AETNA US HEALTHCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 128146-A21 . This is a "HEALTHFIRST" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0C0646 . This is a "HEALTHNET" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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