Healthcare Provider Details

I. General information

NPI: 1003566498
Provider Name (Legal Business Name): SAI KIRAN GUDLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2022
Last Update Date: 06/23/2023
Certification Date: 06/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 ASHLEY AVE RM 202
CHARLESTON SC
29425-2134
US

IV. Provider business mailing address

11522 TURNING HAWK RD
CHARLOTTE NC
28277-3639
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-2575
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberLL89748
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: