Provider Demographics
NPI:1285849513
Name:GANDIKOTA, PRAVEENA (MD)
Entity Type:Individual
Prefix:
First Name:PRAVEENA
Middle Name:
Last Name:GANDIKOTA
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:ONE MEDICAL CENTER BLVD
Mailing Address - Street 2:SUITE 424
Mailing Address - City:UPLAND
Mailing Address - State:PA
Mailing Address - Zip Code:19013
Mailing Address - Country:US
Mailing Address - Phone:610-338-1820
Mailing Address - Fax:610-338-1825
Practice Address - Street 1:ONE MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE 424
Practice Address - City:UPLAND
Practice Address - State:PA
Practice Address - Zip Code:19013
Practice Address - Country:US
Practice Address - Phone:610-338-1820
Practice Address - Fax:610-338-1825
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD440569207RE0101X
PAMT 185538390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program