Healthcare Provider Details

I. General information

NPI: 1265993729
Provider Name (Legal Business Name): PREET GUDIMELLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2019
Last Update Date: 08/24/2022
Certification Date: 08/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 HYDE ST
WAKEMAN OH
44889-9301
US

IV. Provider business mailing address

272 BENEDICT AVE
NORWALK OH
44857-2374
US

V. Phone/Fax

Practice location:
  • Phone: 440-839-2226
  • Fax: 440-839-1339
Mailing address:
  • Phone: 419-668-8101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35.146400
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: