Provider Demographics
NPI:1952405359
Name:GUNDLURU, HARISH (MD)
Entity Type:Individual
Prefix:
First Name:HARISH
Middle Name:
Last Name:GUNDLURU
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 1:1450 CHAPEL ST.
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511
Mailing Address - Country:US
Mailing Address - Phone:203-789-4044
Mailing Address - Fax:203-789-3007
Practice Address - Street 1:1450 CHAPEL ST.
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511
Practice Address - Country:US
Practice Address - Phone:203-789-4044
Practice Address - Fax:203-789-3007
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT037815207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001378159Medicaid
G91780Medicare UPIN
P00620730Medicare PIN
CT110007584Medicare ID - Type Unspecified
CT110010227Medicare PIN