Provider Demographics
NPI:1205952173
Name:GUDE, PRABHAVATHI VENKATA (MD)
Entity type:Individual
Prefix:
First Name:PRABHAVATHI
Middle Name:VENKATA
Last Name:GUDE
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 1:570 LEE STREET
Mailing Address - Street 2:RARITAN BAY MENTAL HEALTH CENTER
Mailing Address - City:PERTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08861-3053
Mailing Address - Country:US
Mailing Address - Phone:732-442-1666
Mailing Address - Fax:
Practice Address - Street 1:570 LEE STREET
Practice Address - Street 2:RARITAN BAY MENTAL HEALTH CENTER
Practice Address - City:PERTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08861-3053
Practice Address - Country:US
Practice Address - Phone:732-442-1666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA038035002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry