Provider Demographics
NPI:1932363876
Name:GADDAM, ANITHA (MD)
Entity Type:Individual
Prefix:MS
First Name:ANITHA
Middle Name:
Last Name:GADDAM
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 1:2702 NORTH 3RD STREET
Mailing Address - Street 2:4020
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004
Mailing Address - Country:US
Mailing Address - Phone:602-323-3344
Mailing Address - Fax:602-323-3496
Practice Address - Street 1:635 EAST BASELINE ROAD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042
Practice Address - Country:US
Practice Address - Phone:602-243-7277
Practice Address - Fax:602-243-1235
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ44481207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ715337Medicaid