Provider Demographics
NPI:1366455966
Name:GURUBHAGAVATULA, INDIRA (MD)
Entity Type:Individual
Prefix:
First Name:INDIRA
Middle Name:
Last Name:GURUBHAGAVATULA
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 1:3624 MARKET ST STE 205
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-2616
Mailing Address - Country:US
Mailing Address - Phone:215-662-7772
Mailing Address - Fax:215-349-8038
Practice Address - Street 1:3624 MARKET ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-2614
Practice Address - Country:US
Practice Address - Phone:215-662-7772
Practice Address - Fax:215-349-8038
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA053054L207R00000X, 207RC0200X, 207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease