Provider Demographics
NPI:1073561858
Name:GADDAM, ELIYAZAR (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIYAZAR
Middle Name:
Last Name:GADDAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:951 COMMERCE PKWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-4040
Mailing Address - Country:US
Mailing Address - Phone:419-998-4575
Mailing Address - Fax:419-998-4586
Practice Address - Street 1:951 COMMERCE PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-4040
Practice Address - Country:US
Practice Address - Phone:419-224-5915
Practice Address - Fax:419-224-5918
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.127156207RC0000X
IL036083544207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1073561858Medicaid
IL036083544Medicaid