Healthcare Provider Details

I. General information

NPI: 1689667032
Provider Name (Legal Business Name): SUJATHA GUNNALA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date: 03/24/2006
Reactivation Date: 04/03/2006

III. Provider practice location address

3125 N 32ND ST SUITE 200
PHOENIX AZ
85018-6281
US

IV. Provider business mailing address

3125 N 32ND ST SUITE 200
PHOENIX AZ
85018-6281
US

V. Phone/Fax

Practice location:
  • Phone: 602-956-7481
  • Fax: 602-956-7591
Mailing address:
  • Phone: 602-956-7481
  • Fax: 602-956-7591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number11933
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: