Provider Demographics
NPI:1497183974
Name:MADHAV A GUDI, MD, PLLC
Entity Type:Organization
Organization Name:MADHAV A GUDI, MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MADHAV
Authorized Official - Middle Name:A
Authorized Official - Last Name:GUDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-930-5230
Mailing Address - Street 1:1368 83RD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11228-3035
Mailing Address - Country:US
Mailing Address - Phone:718-745-0860
Mailing Address - Fax:347-560-6040
Practice Address - Street 1:8721 5TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-5230
Practice Address - Country:US
Practice Address - Phone:718-745-0860
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-22
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY122837302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY002797722Medicaid
NY002797722Medicaid