=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750666517
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. RADHIKA GUTTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2011
-----------------------------------------------------
Last Update Date | 10/12/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25421 EASTERN MARKETPLACE PLZ
-----------------------------------------------------
City | CHANTILLY
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20152-5780
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-327-7817
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14061 LOTUS LN APT 1012
-----------------------------------------------------
City | CENTREVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20120-7403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-354-8363
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 0202210212
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------