Provider Demographics
NPI:1346458767
Name:GUNDABOLU, BHASKAR (MD)
Entity Type:Individual
Prefix:DR
First Name:BHASKAR
Middle Name:
Last Name:GUNDABOLU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 W CENTRAL AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-3834
Mailing Address - Country:US
Mailing Address - Phone:419-537-5111
Mailing Address - Fax:419-537-5131
Practice Address - Street 1:2100 W CENTRAL AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3834
Practice Address - Country:US
Practice Address - Phone:419-537-5111
Practice Address - Fax:419-537-5131
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35088652207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9567063OtherAETNA
OH6870OtherPARAMOUNT
OH2831243Medicaid
OH66501560001OtherMEDICAL MUTUAL
OH751132OtherBUCKEYE
OH000000541140OtherANTHEM
OH2831243Medicaid
OH751132OtherBUCKEYE