Healthcare Provider Details

I. General information

NPI: 1750350575
Provider Name (Legal Business Name): PRAVEEN B GULATI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SOUTH ST
SOUTHBRIDGE MA
01550-4051
US

IV. Provider business mailing address

79 SAYLES ST
SOUTHBRIDGE MA
01550-1729
US

V. Phone/Fax

Practice location:
  • Phone: 508-765-9771
  • Fax: 508-764-9410
Mailing address:
  • Phone: 508-764-0482
  • Fax: 508-764-9410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number46377
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number46377
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number46377
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: