Healthcare Provider Details

I. General information

NPI: 1497750046
Provider Name (Legal Business Name): PRASAD R. GUDAVALLI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 11/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7702 - 16TH AVE
BROOKLYN NY
11214-1002
US

IV. Provider business mailing address

7702 - 16TH AVE
BROOKLYN NY
11214-1002
US

V. Phone/Fax

Practice location:
  • Phone: 718-645-2929
  • Fax: 718-621-4119
Mailing address:
  • Phone: 718-645-2929
  • Fax: 718-621-4119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number128146
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: