Provider Demographics
NPI:1093069411
Name:GADDAM, KISHORE KUMAR (MD)
Entity Type:Individual
Prefix:
First Name:KISHORE
Middle Name:KUMAR
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 1:21141 STERLING AVE UNIT 1
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19947-5571
Mailing Address - Country:US
Mailing Address - Phone:302-856-6967
Mailing Address - Fax:302-855-0744
Practice Address - Street 1:21141 STERLING AVE UNIT 1
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:DE
Practice Address - Zip Code:19947-5571
Practice Address - Country:US
Practice Address - Phone:302-856-6967
Practice Address - Fax:302-855-0744
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-07
Last Update Date:2023-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10025067208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics