Provider Demographics
NPI:1467706846
Name:GUNTREDDI, GIRIDHAR (MD)
Entity Type:Individual
Prefix:
First Name:GIRIDHAR
Middle Name:
Last Name:GUNTREDDI
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 1:3401 CIVIC CENTER BLVD
Mailing Address - Street 2:SUITE-M975
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-3364
Mailing Address - Country:US
Mailing Address - Phone:973-573-1527
Mailing Address - Fax:
Practice Address - Street 1:3401 CIVIC CENTER BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-3364
Practice Address - Country:US
Practice Address - Phone:218-694-2384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-06
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN57756208000000X, 208M00000X
PAMD4624172080P0204X
#39390200000X
NJ25MA11861300208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJH3021593OtherQUALCARE PPO NETWORK ENHANCED PLAN