Provider Demographics
NPI:1265993729
Name:GUDIMELLA, PREET (MD)
Entity type:Individual
Prefix:
First Name:PREET
Middle Name:
Last Name:GUDIMELLA
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 1:272 BENEDICT AVE
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:OH
Mailing Address - Zip Code:44857-2374
Mailing Address - Country:US
Mailing Address - Phone:419-668-8101
Mailing Address - Fax:
Practice Address - Street 1:24 HYDE ST
Practice Address - Street 2:
Practice Address - City:WAKEMAN
Practice Address - State:OH
Practice Address - Zip Code:44889-9301
Practice Address - Country:US
Practice Address - Phone:440-839-2226
Practice Address - Fax:440-839-1339
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-27
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.146400207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine