Healthcare Provider Details

I. General information

NPI: 1497906093
Provider Name (Legal Business Name): SRUJANI GADDAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2008
Last Update Date: 01/09/2024
Certification Date: 01/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 W PINE AVE
LONGWOOD FL
32750-4168
US

IV. Provider business mailing address

PO BOX 616788
ORLANDO FL
32861-6788
US

V. Phone/Fax

Practice location:
  • Phone: 321-207-0172
  • Fax: 321-201-0175
Mailing address:
  • Phone: 407-533-6835
  • Fax: 407-770-0661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME125820
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME125820
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: