Healthcare Provider Details

I. General information

NPI: 1821364498
Provider Name (Legal Business Name): SATYA KISHORE GUTTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2012
Last Update Date: 02/18/2022
Certification Date: 02/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8701 W WATERTOWN PLANK RD MEDICAL COLLEGE OF WISCONSIN AFFILIATED HOSPITALS PROGR
MILWAUKEE WI
53226-3548
US

IV. Provider business mailing address

4656 W JEFFERSON BLVD STE 201
FORT WAYNE IN
46804-6857
US

V. Phone/Fax

Practice location:
  • Phone: 414-955-8998
  • Fax: 414-955-6299
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number01086475A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number61391
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number60291
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number01086475A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: