Provider Demographics
NPI:1083600282
Name:GUNDKALLI, RAMIZ (MD)
Entity Type:Individual
Prefix:
First Name:RAMIZ
Middle Name:
Last Name:GUNDKALLI
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:PO BOX 106002
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30348-6002
Mailing Address - Country:US
Mailing Address - Phone:352-867-8898
Mailing Address - Fax:352-732-6282
Practice Address - Street 1:1324 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-4543
Practice Address - Country:US
Practice Address - Phone:352-867-8898
Practice Address - Fax:352-732-6282
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2007-07-08
Deactivation Date:2006-05-02
Deactivation Code:
Reactivation Date:2006-08-11
Provider Licenses
StateLicense IDTaxonomies
FLME91287207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL52100OtherBLUE CROSS BLUE SHIELD
FL271140100Medicaid
FL271140100Medicaid
FL52100OtherBLUE CROSS BLUE SHIELD