Healthcare Provider Details

I. General information

NPI: 1083795264
Provider Name (Legal Business Name): GAUTAMI KONDAMODI RAO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 02/16/2022
Certification Date: 02/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

242 W PARKWAY
POMPTON PLAINS NJ
07444-1029
US

IV. Provider business mailing address

PO BOX 416457
BOSTON MA
02241-6457
US

V. Phone/Fax

Practice location:
  • Phone: 908-522-2829
  • Fax: 908-522-6147
Mailing address:
  • Phone: 844-362-1735
  • Fax: 973-290-7495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number044606
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number25MA08365500
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number25MA08365500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: