Provider Demographics
NPI:1932620218
Name:GUDIMELLA, PREETI (MD)
Entity Type:Individual
Prefix:
First Name:PREETI
Middle Name:
Last Name:GUDIMELLA
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 1:272 BENEDICT AVE
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:OH
Mailing Address - Zip Code:44857-2374
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24 HYDE ST
Practice Address - Street 2:
Practice Address - City:WAKEMAN
Practice Address - State:OH
Practice Address - Zip Code:44889-9301
Practice Address - Country:US
Practice Address - Phone:440-839-2226
Practice Address - Fax:440-839-1339
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301113335207Q00000X
OH35.140974207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0426729Medicaid