Healthcare Provider Details

I. General information

NPI: 1598813578
Provider Name (Legal Business Name): BHANUMATHI GUTTIKONDA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 WINDSOR ROAD
STATEN ISLAND NY
10314
US

IV. Provider business mailing address

165 WINDSOR ROAD
STATEN ISLAND NY
10314
US

V. Phone/Fax

Practice location:
  • Phone: 718-273-6909
  • Fax: 718-556-1593
Mailing address:
  • Phone: 718-273-6909
  • Fax: 718-556-1593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number154113
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: