Healthcare Provider Details

I. General information

NPI: 1356970057
Provider Name (Legal Business Name): ANIRUDH GUDURU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2020
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 N PRINCE FREDERICK BLVD
PRINCE FREDERICK MD
20678-3193
US

IV. Provider business mailing address

24035 THREE NOTCH RD
HOLLYWOOD MD
20636-4871
US

V. Phone/Fax

Practice location:
  • Phone: 410-535-4116
  • Fax: 410-414-8480
Mailing address:
  • Phone: 301-373-7900
  • Fax: 301-373-6900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberD0102410
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: