Provider Demographics
NPI:1790007854
Name:GUDAPATI, SRIDHAR
Entity Type:Individual
Prefix:MR
First Name:SRIDHAR
Middle Name:
Last Name:GUDAPATI
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 1:6075 FALLFISH CT
Mailing Address - Street 2:
Mailing Address - City:NEW MARKET
Mailing Address - State:MD
Mailing Address - Zip Code:21774-6742
Mailing Address - Country:US
Mailing Address - Phone:718-791-6004
Mailing Address - Fax:
Practice Address - Street 1:17703 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-7850
Practice Address - Country:US
Practice Address - Phone:240-420-5310
Practice Address - Fax:240-420-5356
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-17
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP439420183500000X
MD16834183500000X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist