Healthcare Provider Details

I. General information

NPI: 1194872713
Provider Name (Legal Business Name): JYOTHI DYAVANAPALLI GUDLA M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JYOTHI D GUDLA M.D

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4808 MUNSON ST NW
CANTON OH
44718-3613
US

IV. Provider business mailing address

4808 MUNSON ST NW
CANTON OH
44718-3613
US

V. Phone/Fax

Practice location:
  • Phone: 330-622-0207
  • Fax: 330-832-3499
Mailing address:
  • Phone: 330-460-4115
  • Fax: 330-832-3499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number35-083145
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35-083145
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number35.083145
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35.083145
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: