Provider Demographics
NPI:1497750046
Name:GUDAVALLI, PRASAD R (MD)
Entity Type:Individual
Prefix:DR
First Name:PRASAD
Middle Name:R
Last Name:GUDAVALLI
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 1:7702 - 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-1002
Mailing Address - Country:US
Mailing Address - Phone:718-645-2929
Mailing Address - Fax:718-621-4119
Practice Address - Street 1:7702 - 16TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-1002
Practice Address - Country:US
Practice Address - Phone:718-645-2929
Practice Address - Fax:718-621-4119
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY128146174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00366349Medicaid
NY0046803OtherGROUP HEALTH INC.
NY069508793OtherUNITED HEALTHCARE
NY1000016766OtherAFFINITY
NY4556190OtherCIGNA HEALTHCARE
NYOXFORDOtherP393018
NY069508709OtherOXFORD HEALTH PLAN
NY07A361OtherBLUE CROSS & BLUE SHIELD
NY97367OtherAETNA US HEALTHCARE
NY128146-A21OtherHEALTHFIRST
NY0C0646OtherHEALTHNET
NY069508793OtherUNITED HEALTHCARE
NY128146-A21OtherHEALTHFIRST