Healthcare Provider Details

I. General information

NPI: 1447257795
Provider Name (Legal Business Name): P. RAO GUMMADI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 CAREW ST SUITE 220
FORT WAYNE IN
46805-4788
US

IV. Provider business mailing address

1818 CAREW ST SUITE 220
FORT WAYNE IN
46805-4788
US

V. Phone/Fax

Practice location:
  • Phone: 260-482-1004
  • Fax: 260-483-7894
Mailing address:
  • Phone: 260-482-1004
  • Fax: 260-483-7894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number01030939A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: