Provider Demographics
NPI:1750350575
Name:GULATI, PRAVEEN B (MD)
Entity type:Individual
Prefix:
First Name:PRAVEEN
Middle Name:B
Last Name:GULATI
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 1:79 SAYLES ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550-1729
Mailing Address - Country:US
Mailing Address - Phone:508-764-0482
Mailing Address - Fax:508-764-9410
Practice Address - Street 1:100 SOUTH ST
Practice Address - Street 2:
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550-4051
Practice Address - Country:US
Practice Address - Phone:508-765-9771
Practice Address - Fax:508-764-9410
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA463772085N0904X, 2085R0202X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Not Answered2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Not Answered2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2090244Medicaid
MA38409OtherFALLON COMMUNITY HLTH PLA
MAJ09884OtherBLUE SHIELD
MA316123OtherTUFTS HEALTH PLAN
MA24783OtherHARVARD PILGRIM
MA38409OtherFALLON COMMUNITY HLTH PLA
MA24783OtherHARVARD PILGRIM