Provider Demographics
NPI:1679068712
Name:GAUDAM, NITHYALAKSHMI (MD)
Entity Type:Individual
Prefix:
First Name:NITHYALAKSHMI
Middle Name:
Last Name:GAUDAM
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 1:620 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-3923
Mailing Address - Country:US
Mailing Address - Phone:731-541-5000
Mailing Address - Fax:731-660-8739
Practice Address - Street 1:620 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3923
Practice Address - Country:US
Practice Address - Phone:731-541-5000
Practice Address - Fax:731-660-8739
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-29
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018017087207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine