Healthcare Provider Details

I. General information

NPI: 1851889893
Provider Name (Legal Business Name): PUJITHA KUDARAVALLI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2018
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 E ADAMS ST
SYRACUSE NY
13210-2306
US

IV. Provider business mailing address

750 E ADAMS ST
SYRACUSE NY
13210-2306
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-5240
  • Fax: 315-464-3751
Mailing address:
  • Phone: 469-990-9457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number1019917
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: