Healthcare Provider Details

I. General information

NPI: 1588416028
Provider Name (Legal Business Name): SUMAJA REDDY GOGURI M.B.B.S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2024
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 MAIN ST
BRIDGEPORT CT
06606-4201
US

IV. Provider business mailing address

2800 MAIN STREET DEPARTMENT OF MEDICAL EDUCATION
BRIDGEPORT CT
06606
US

V. Phone/Fax

Practice location:
  • Phone: 475-210-5440
  • Fax: 475-210-5022
Mailing address:
  • Phone: 475-210-5440
  • Fax: 475-210-5022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number77450
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: