Provider Demographics
NPI:1093764656
Name:GADUDASU, GOURI (MD)
Entity Type:Individual
Prefix:DR
First Name:GOURI
Middle Name:
Last Name:GADUDASU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:GOURI
Other - Middle Name:
Other - Last Name:SHIRUMALLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:231 D AVE
Mailing Address - Street 2:APT #12
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28144-6831
Mailing Address - Country:US
Mailing Address - Phone:704-707-3966
Mailing Address - Fax:
Practice Address - Street 1:1601 BRENNER AVE
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-2515
Practice Address - Country:US
Practice Address - Phone:704-638-9000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME#90774207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLI24460Medicare UPIN