Provider Demographics
NPI:1811176704
Name:GONUGUNTLA, ANURADHA (MD)
Entity type:Individual
Prefix:
First Name:ANURADHA
Middle Name:
Last Name:GONUGUNTLA
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 1:1800 GLENSIDE DR
Mailing Address - Street 2:STE 105
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-3769
Mailing Address - Country:US
Mailing Address - Phone:804-288-2762
Mailing Address - Fax:804-285-0088
Practice Address - Street 1:5360 TWIN HICKORY RD
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-5682
Practice Address - Country:US
Practice Address - Phone:804-346-3200
Practice Address - Fax:804-346-4075
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDRL10545207Q00000X
SD7823207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND12083Medicaid
VA383787YWAUMedicare PIN
ND12083Medicaid