Provider Demographics
NPI:1942390869
Name:GURUBHAGAVATULA, SARADA (MD)
Entity Type:Individual
Prefix:
First Name:SARADA
Middle Name:
Last Name:GURUBHAGAVATULA
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 1:95 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07960-6092
Mailing Address - Country:US
Mailing Address - Phone:973-538-5210
Mailing Address - Fax:973-644-9657
Practice Address - Street 1:150 PARK AVE
Practice Address - Street 2:
Practice Address - City:FLORHAM PARK
Practice Address - State:NJ
Practice Address - Zip Code:07932-1049
Practice Address - Country:US
Practice Address - Phone:973-538-5210
Practice Address - Fax:973-644-9657
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08170200207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0121428Medicaid
NJ105658BL0Medicare PIN
NJH29868Medicare UPIN
NJ105658C3WMedicare PIN