Healthcare Provider Details

I. General information

NPI: 1417458175
Provider Name (Legal Business Name): PRAKASH S GUDSOORKAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2018
Last Update Date: 01/27/2020
Certification Date: 01/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 GOODMAN ST
CINCINNATI OH
45219-2364
US

IV. Provider business mailing address

2830 VICTORY PKWY
CINCINNATI OH
45206-1785
US

V. Phone/Fax

Practice location:
  • Phone: 513-558-5468
  • Fax: 513-558-4309
Mailing address:
  • Phone: 513-245-3072
  • Fax: 513-585-5511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number35.138518
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: