Provider Demographics
NPI:1821364498
Name:GUTTA, SATYA KISHORE (MD)
Entity Type:Individual
Prefix:DR
First Name:SATYA
Middle Name:KISHORE
Last Name:GUTTA
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 1:4656 W JEFFERSON BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6857
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8701 W WATERTOWN PLANK RD
Practice Address - Street 2:MEDICAL COLLEGE OF WISCONSIN AFFILIATED HOSPITALS PROGR
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3548
Practice Address - Country:US
Practice Address - Phone:414-955-8998
Practice Address - Fax:414-955-6299
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-28
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01086475A2084A0401X, 2084P0800X
WI613912084P0805X
WI60291208D00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program