Provider Demographics
NPI:1497919179
Name:GUNNALA, VISHAL
Entity Type:Individual
Prefix:
First Name:VISHAL
Middle Name:
Last Name:GUNNALA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 E CAMELBACK RD
Mailing Address - Street 2:STE 250
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2311
Mailing Address - Country:US
Mailing Address - Phone:602-933-1813
Mailing Address - Fax:602-933-1820
Practice Address - Street 1:1919 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7710
Practice Address - Country:US
Practice Address - Phone:602-933-1784
Practice Address - Fax:602-933-4298
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-11
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ516752080P0203X, 2080P0203X
IL125-054240208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics