Provider Demographics
NPI:1487663415
Name:GUJAVARTY, KRISHNA R S (MD)
Entity Type:Individual
Prefix:
First Name:KRISHNA
Middle Name:R S
Last Name:GUJAVARTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KRISHNAREDDY
Other - Middle Name:S
Other - Last Name:GUJAVARTY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:49 DOLPHIN LANE EAST
Mailing Address - Street 2:
Mailing Address - City:COPIAGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11726-5415
Mailing Address - Country:US
Mailing Address - Phone:631-331-0028
Mailing Address - Fax:631-608-3387
Practice Address - Street 1:49 DOLPHIN LANE EAST
Practice Address - Street 2:
Practice Address - City:COPIAGUE
Practice Address - State:NY
Practice Address - Zip Code:11726
Practice Address - Country:US
Practice Address - Phone:631-331-0028
Practice Address - Fax:631-608-3387
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1414072084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00604040Medicaid
NY00604040Medicaid
B15721Medicare UPIN