MEDICARE: DR. PRASAD R. GUDAVALLI MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	128146	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0046803	OTHER	NY	GROUP HEALTH INC.
3	069508793	OTHER	NY	UNITED HEALTHCARE
4	1000016766	OTHER	NY	AFFINITY
5	4556190	OTHER	NY	CIGNA HEALTHCARE
6	OXFORD	OTHER	NY	P393018
7	069508709	OTHER	NY	OXFORD HEALTH PLAN
8	07A361	OTHER	NY	BLUE CROSS & BLUE SHIELD
9	97367	OTHER	NY	AETNA US HEALTHCARE
10	128146-A21	OTHER	NY	HEALTHFIRST
11	0C0646	OTHER	NY	HEALTHNET

General Provider Information

NPI Number	:	1497750046
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PRASAD R. GUDAVALLI MD

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

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

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/20/2005
Last Update Date	:	11/05/2012

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