Provider Demographics
NPI:1730130675
Name:NAIDU, GONGUNTLA V (MD)
Entity Type:Individual
Prefix:
First Name:GONGUNTLA
Middle Name:V
Last Name:NAIDU
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 1:5535 DELMAR BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112-3005
Mailing Address - Country:US
Mailing Address - Phone:314-879-6363
Mailing Address - Fax:
Practice Address - Street 1:5535 DELMAR BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63112-3005
Practice Address - Country:US
Practice Address - Phone:314-879-6363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6200207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200180008Medicaid
MO200180008Medicaid
MO50452931Medicare ID - Type Unspecified