Provider Demographics
NPI:1750310801
Name:GUNDELLY, ASHWINI (MD)
Entity type:Individual
Prefix:
First Name:ASHWINI
Middle Name:
Last Name:GUNDELLY
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:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024-1700
Practice Address - Country:US
Practice Address - Phone:262-375-3700
Practice Address - Fax:262-376-6032
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45041207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34377800Medicaid
WIP00449427OtherRR MEDICARE
WI01994-0186Medicare PIN
WI46236-0186Medicare PIN
WIH84651Medicare UPIN