Provider Demographics
NPI:1467662601
Name:GUNDAJI, SURESH (MBBS)
Entity Type:Individual
Prefix:
First Name:SURESH
Middle Name:
Last Name:GUNDAJI
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:110 LIBERTY ST
Mailing Address - Street 2:SIGNATURE HEALTHCARE
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-5521
Mailing Address - Country:US
Mailing Address - Phone:508-894-0400
Mailing Address - Fax:508-894-0412
Practice Address - Street 1:110 LIBERTY ST
Practice Address - Street 2:SIGNATURE HEALTHCARE
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5521
Practice Address - Country:US
Practice Address - Phone:508-894-0400
Practice Address - Fax:508-894-0412
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2024-01-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA257064207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA07814Medicaid