Provider Demographics
NPI:1356822407
Name:GUDIVADA, ABHIJIT
Entity Type:Individual
Prefix:
First Name:ABHIJIT
Middle Name:
Last Name:GUDIVADA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 WINSTON RD
Mailing Address - Street 2:
Mailing Address - City:JONESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28642-2255
Mailing Address - Country:US
Mailing Address - Phone:336-835-6407
Mailing Address - Fax:336-526-8329
Practice Address - Street 1:988 1ST AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-4150
Practice Address - Country:US
Practice Address - Phone:212-755-6632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-27
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28154183500000X
NY066511183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC28154OtherNC PHARMACIST LICENSE
NY066511OtherNY PHARMACIST LICENSE