Provider Demographics
NPI:1710250899
Name:GUNDABOLU, KRISHNA (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISHNA
Middle Name:
Last Name:GUNDABOLU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:987680 NEBRASKA MEDICAL CENTER
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-6520
Mailing Address - Country:US
Mailing Address - Phone:402-559-8052
Mailing Address - Fax:
Practice Address - Street 1:987680 NEBRASKA MEDICAL CTR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-7680
Practice Address - Country:US
Practice Address - Phone:402-559-8052
Practice Address - Fax:402-559-6520
Is Sole Proprietor?:No
Enumeration Date:2012-02-20
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106238207RH0003X
MN55639207RH0003X
NE27263207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDENROLLEDMedicaid
IAENROLLEDMedicaid
MNENROLLEDMedicaid
MN830000848Medicare PIN