Healthcare Provider Details

I. General information

NPI: 1972066769
Provider Name (Legal Business Name): HARIKA GUDURU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 10/13/2022
Certification Date: 09/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24560 SOUTHPOINT DR STE 220
ALDIE VA
20105-3505
US

IV. Provider business mailing address

22411 CLAUDE MOORE DR
ASHBURN VA
20148-3206
US

V. Phone/Fax

Practice location:
  • Phone: 571-570-4300
  • Fax:
Mailing address:
  • Phone: 513-678-4806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101276857
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: