Provider Demographics
NPI:1407223506
Name:CHITALAPUDI, GOURI
Entity Type:Individual
Prefix:
First Name:GOURI
Middle Name:
Last Name:CHITALAPUDI
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 1:2390 LINSON STREET
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77703
Mailing Address - Country:US
Mailing Address - Phone:309-569-9100
Mailing Address - Fax:
Practice Address - Street 1:819 AUBURN HILL DR APT C
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46224
Practice Address - Country:US
Practice Address - Phone:309-569-9100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-25
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05012769A225100000X
IL070023568225100000X
NY042654225100000X
TX1302300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist