Provider Demographics
NPI:1649465600
Name:GUJJA, PRADEEP REDDY (MD)
Entity type:Individual
Prefix:
First Name:PRADEEP
Middle Name:REDDY
Last Name:GUJJA
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 1:100 W MCCREIGHT AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504-1885
Mailing Address - Country:US
Mailing Address - Phone:937-323-1404
Mailing Address - Fax:937-523-9555
Practice Address - Street 1:100 W MCCREIGHT AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504-1885
Practice Address - Country:US
Practice Address - Phone:937-323-1404
Practice Address - Fax:937-523-9555
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.092832207R00000X
OH92832207RC0001X
OH35092832207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4272901Medicare PIN