Provider Demographics
NPI:1750393237
Name:MIDATHALA, GNANESWARA V (MD)
Entity type:Individual
Prefix:DR
First Name:GNANESWARA
Middle Name:V
Last Name:MIDATHALA
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:PO BOX 100183
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0183
Mailing Address - Country:US
Mailing Address - Phone:352-392-0140
Mailing Address - Fax:
Practice Address - Street 1:3130 SW 27TH AVE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-4306
Practice Address - Country:US
Practice Address - Phone:352-547-2097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360925062084P0800X
SC868552084P0800X
FLME1093252084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG69359Medicare UPIN