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General NPI Number Information
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NPI Number | 1790297935
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Entity Type | Organization
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Legal Business Name | DIAMOND MEDICAL GROUP
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Dates
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Enumeration Date | 10/27/2017
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Last Update Date | 02/14/2018
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Provider Practice Location Address
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Address Line | 830 PARK EAST BLVD
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City | LAFAYETTE
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State | IN
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Zip | 47905-0778
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Country | US
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Telephone | 219-448-0369
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Fax |
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Provider Business Mailing Address
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Address Line | 3679 WAKEFIELD DR
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City | WEST LAFAYETTE
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State | IN
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Zip | 47906-8708
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Country | US
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Telephone | 219-448-0369
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | BENERJI GUDAPATI
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Credential | MD
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Telephone | 219-448-0369
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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