Healthcare Provider Details

I. General information

NPI: 1164673232
Provider Name (Legal Business Name): SREENIVAS DUTT GUNTURU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2008
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 TAMARACK AVE
SOUTH WINDSOR CT
06074-5562
US

IV. Provider business mailing address

MANCHESTER PEDIATRIC ASSOCIATES 2701 TAMARACK AVENUE
SOUTH WINDSOR CT
06074
US

V. Phone/Fax

Practice location:
  • Phone: 860-647-8282
  • Fax: 860-647-8399
Mailing address:
  • Phone: 860-647-8282
  • Fax: 860-647-8399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number62234
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101248556
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: