Healthcare Provider Details

I. General information

NPI: 1750700852
Provider Name (Legal Business Name): PRABHAVATHI GUMMALLA M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2014
Last Update Date: 02/09/2023
Certification Date: 02/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 CIVIC CENTER BLVD
PHILADELPHIA PA
19104-4319
US

IV. Provider business mailing address

2-10 LINDEN AVE
HADDONFIELD NJ
08033-2556
US

V. Phone/Fax

Practice location:
  • Phone: 917-715-5360
  • Fax:
Mailing address:
  • Phone: 917-715-5360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number25MA10793600
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number285065
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2080S0012X
TaxonomyPediatric Sleep Medicine Physician
License NumberMD458931
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code2080S0012X
TaxonomyPediatric Sleep Medicine Physician
License Number25MA10793600
License Number StateNJ
# 5
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License NumberMD458931
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: