Healthcare Provider Details

I. General information

NPI: 1487663415
Provider Name (Legal Business Name): KRISHNA R S GUJAVARTY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: KRISHNAREDDY S GUJAVARTY MD

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 DOLPHIN LANE EAST
COPIAGUE NY
11726
US

IV. Provider business mailing address

49 DOLPHIN LANE EAST
COPIAGUE NY
11726-5415
US

V. Phone/Fax

Practice location:
  • Phone: 631-331-0028
  • Fax: 631-608-3387
Mailing address:
  • Phone: 631-331-0028
  • Fax: 631-608-3387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number141407
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: