Provider Demographics
NPI:1497906093
Name:GADDAM, SRUJANI (MD)
Entity Type:Individual
Prefix:
First Name:SRUJANI
Middle Name:
Last Name:GADDAM
Suffix:
Gender:F
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:PO BOX 616788
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32861-6788
Mailing Address - Country:US
Mailing Address - Phone:407-533-6835
Mailing Address - Fax:407-770-0661
Practice Address - Street 1:175 W PINE AVE
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-4168
Practice Address - Country:US
Practice Address - Phone:321-207-0172
Practice Address - Fax:321-201-0175
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-02
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME125820208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110748300Medicaid