Provider Demographics
NPI:1609996792
Name:GAJENDRAGADKAR, SUREKHA S (RPT)
Entity Type:Individual
Prefix:
First Name:SUREKHA
Middle Name:S
Last Name:GAJENDRAGADKAR
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 YELLOW WOOD WAY
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-7126
Mailing Address - Country:US
Mailing Address - Phone:304-255-2376
Mailing Address - Fax:304-255-7120
Practice Address - Street 1:9 YELLOW WOOD WAY
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-7126
Practice Address - Country:US
Practice Address - Phone:304-255-2376
Practice Address - Fax:304-255-7120
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
000398225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7302339000Medicaid
WV7332914OtherAETNA
WVP00687439OtherRAILROAD MEDICARE
WV609079OtherCARELINK COVENTRY
WV7471484OtherCIGNA
WV001975072OtherBCBS
WV001975072OtherBCBS
WV7302339000Medicaid