Healthcare Provider Details

I. General information

NPI: 1205952173
Provider Name (Legal Business Name): PRABHAVATHI VENKATA GUDE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 07/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

570 LEE STREET RARITAN BAY MENTAL HEALTH CENTER
PERTH AMBOY NJ
08861-3053
US

IV. Provider business mailing address

570 LEE STREET RARITAN BAY MENTAL HEALTH CENTER
PERTH AMBOY NJ
08861-3053
US

V. Phone/Fax

Practice location:
  • Phone: 732-442-1666
  • Fax:
Mailing address:
  • Phone: 732-442-1666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number25MA03803500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: