Provider Demographics
NPI:1265503221
Name:GUNNALA, SHAILAJA (MD)
Entity Type:Individual
Prefix:MRS
First Name:SHAILAJA
Middle Name:
Last Name:GUNNALA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHAILAJA
Other - Middle Name:
Other - Last Name:PRATAP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19636 N 27TH AVE
Mailing Address - Street 2:#207
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027
Mailing Address - Country:US
Mailing Address - Phone:623-580-7240
Mailing Address - Fax:623-580-7244
Practice Address - Street 1:19636 N 27TH AVE
Practice Address - Street 2:#207
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027
Practice Address - Country:US
Practice Address - Phone:623-580-7240
Practice Address - Fax:623-580-7244
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27607207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ477845Medicaid
H00067Medicare UPIN
Z28446Medicare ID - Type Unspecified