Healthcare Provider Details

I. General information

NPI: 1568983484
Provider Name (Legal Business Name): MOUNIKA GUDURU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2017
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78 MEDICAL CENTER DR
FISHERSVILLE VA
22939-2332
US

IV. Provider business mailing address

PO BOX 388
FISHERSVILLE VA
22939-0388
US

V. Phone/Fax

Practice location:
  • Phone: 540-332-4400
  • Fax: 540-332-4490
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number8184
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101280886
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: