Healthcare Provider Details

I. General information

NPI: 1649465600
Provider Name (Legal Business Name): PRADEEP REDDY GUJJA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2007
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W MCCREIGHT AVE
SPRINGFIELD OH
45504-1885
US

IV. Provider business mailing address

100 W MCCREIGHT AVE
SPRINGFIELD OH
45504-1885
US

V. Phone/Fax

Practice location:
  • Phone: 937-323-1404
  • Fax: 937-523-9555
Mailing address:
  • Phone: 937-323-1404
  • Fax: 937-523-9555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35.092832
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number92832
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number35092832
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: