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: 07/02/2025
Certification Date: 07/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 PRINCE FREDERICK BLVD
PRINCE FREDERICK MD
20678-3193
US

IV. Provider business mailing address

113 PRYNNWOOD CT
CARY NC
27513-6275
US

V. Phone/Fax

Practice location:
  • Phone: 410-535-4116
  • Fax: 410-414-8480
Mailing address:
  • Phone: 919-931-7715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberD0102410
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: