Provider Demographics
NPI:1326572058
Name:GORUKANTI, ANURADHA (MD)
Entity Type:Individual
Prefix:
First Name:ANURADHA
Middle Name:
Last Name:GORUKANTI
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 1:3849 MCREE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2619
Mailing Address - Country:US
Mailing Address - Phone:479-629-5242
Mailing Address - Fax:
Practice Address - Street 1:725 WELCH RD
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1601
Practice Address - Country:US
Practice Address - Phone:650-497-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-19
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA157301208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program