Provider Demographics
NPI:1316398985
Name:GUDIVADA, SHRAVANA DEEPTHI (MD)
Entity Type:Individual
Prefix:DR
First Name:SHRAVANA DEEPTHI
Middle Name:
Last Name:GUDIVADA
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 1:402 15TH AVE SE STE 201
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-3709
Mailing Address - Country:US
Mailing Address - Phone:253-697-5250
Mailing Address - Fax:
Practice Address - Street 1:402 15TH AVE SE STE 201
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3709
Practice Address - Country:US
Practice Address - Phone:253-697-5250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-24
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125068551207R00000X
WAMD610361972084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine