Healthcare Provider Details

I. General information

NPI: 1861391708
Provider Name (Legal Business Name): MANEESHA GADDIKOPPULA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2026
Last Update Date: 11/05/2026
Certification Date: 11/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 MAIN ST STE 800
BUFFALO NY
14203-2887
US

IV. Provider business mailing address

125 MAIN ST STE 800
BUFFALO NY
14203-2887
US

V. Phone/Fax

Practice location:
  • Phone: 716-504-5739
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: