Healthcare Provider Details

I. General information

NPI: 1669736377
Provider Name (Legal Business Name): JAHNAVE GUDARU M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2012
Last Update Date: 09/22/2022
Certification Date: 09/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 BYPASS RD BLDG B
PIKEVILLE KY
41501-1689
US

IV. Provider business mailing address

PO BOX 432
PIKEVILLE KY
41502-0432
US

V. Phone/Fax

Practice location:
  • Phone: 606-430-2220
  • Fax: 606-432-6665
Mailing address:
  • Phone: 606-430-2220
  • Fax: 606-432-6665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number47507
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: