Healthcare Provider Details

I. General information

NPI: 1619602711
Provider Name (Legal Business Name): SIVA KAMAL GUNTUPALLI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2022
Last Update Date: 07/07/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 S 52ND PLACE
SPRINGFIELD OR
97478-6210
US

IV. Provider business mailing address

PO BOX 1517
PENDLETON OR
97801-0410
US

V. Phone/Fax

Practice location:
  • Phone: 541-746-1166
  • Fax: 541-393-1607
Mailing address:
  • Phone: 877-708-1119
  • Fax: 541-278-8349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD224541
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: