Provider Demographics
NPI:1457639312
Name:GUDDATI, ACHUTA KUMAR (MD)
Entity Type:Individual
Prefix:
First Name:ACHUTA
Middle Name:KUMAR
Last Name:GUDDATI
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 1:100 NICOLLS RD # T15-053
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-0001
Mailing Address - Country:US
Mailing Address - Phone:631-444-3655
Mailing Address - Fax:
Practice Address - Street 1:100 NICOLLS RD # T15053
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-0002
Practice Address - Country:US
Practice Address - Phone:631-444-3655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-26
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA080307207RH0003X, 207RH0003X
NY315533207RH0003X
LA306059207RH0003X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine