Provider Demographics
NPI:1225014046
Name:GUMMADI, SUBHAKAR (MD)
Entity Type:Individual
Prefix:
First Name:SUBHAKAR
Middle Name:
Last Name:GUMMADI
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 1:3600 FLORIDA BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806
Mailing Address - Country:US
Mailing Address - Phone:225-387-7070
Mailing Address - Fax:225-387-7700
Practice Address - Street 1:3600 FLORIDA BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806
Practice Address - Country:US
Practice Address - Phone:225-387-7070
Practice Address - Fax:225-387-7700
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13874R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1438405Medicaid
LA1438405Medicaid
LA4A071Medicare ID - Type Unspecified