Provider Demographics
NPI:1568824449
Name:GONGATI, SUDHARSAN REDDY
Entity Type:Individual
Prefix:
First Name:SUDHARSAN
Middle Name:REDDY
Last Name:GONGATI
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 1:1276 FULTON AVE
Mailing Address - Street 2:RM 219
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10456-3402
Mailing Address - Country:US
Mailing Address - Phone:718-992-7669
Mailing Address - Fax:
Practice Address - Street 1:1650 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-7679
Practice Address - Country:US
Practice Address - Phone:718-960-1216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-22
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY310295207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine