Provider Demographics
NPI:1275620650
Name:GUBBI, SMITHA AYODHYARAM (MD)
Entity Type:Individual
Prefix:
First Name:SMITHA
Middle Name:AYODHYARAM
Last Name:GUBBI
Suffix:
Gender:F
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 416457
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-6457
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 UNION AVE
Practice Address - Street 2:BRIDGEWATER INTERNAL MEDICINE SUITE E
Practice Address - City:BRIDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:08807
Practice Address - Country:US
Practice Address - Phone:908-685-1818
Practice Address - Fax:908-685-8225
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07648800207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0025003Medicaid
079784CVKMedicare ID - Type Unspecified
I11396Medicare UPIN