Provider Demographics
NPI:1750700852
Name:GUMMALLA, PRABHAVATHI (MD)
Entity type:Individual
Prefix:DR
First Name:PRABHAVATHI
Middle Name:
Last Name:GUMMALLA
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 1:2-10 LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:HADDONFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08033-2556
Mailing Address - Country:US
Mailing Address - Phone:917-715-5360
Mailing Address - Fax:
Practice Address - Street 1:3401 CIVIC CENTER BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4319
Practice Address - Country:US
Practice Address - Phone:917-715-5360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-16
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA107936002080P0214X, 2080S0012X
NY2850652080P0214X
PAMD4589312080S0012X, 2080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric PulmonologyGroup - Multi-Specialty
No2080S0012XAllopathic & Osteopathic PhysiciansPediatricsSleep MedicineGroup - Multi-Specialty