Provider Demographics
NPI:1700523180
Name:GADDIPATI, PHANINDRA (MD)
Entity Type:Individual
Prefix:
First Name:PHANINDRA
Middle Name:
Last Name:GADDIPATI
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 1:502 E SPRINGFIELD AVE APT 305
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-5587
Mailing Address - Country:US
Mailing Address - Phone:719-338-2263
Mailing Address - Fax:
Practice Address - Street 1:1959 NE PACIFIC ST
Practice Address - Street 2:RR210
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-2529
Practice Address - Country:US
Practice Address - Phone:719-338-2263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-17
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.079926207R00000X
WAMDRE.ML.614247922085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine