Basic Information
| Provider Information | |||||||||
| NPI: | 1194872713 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUDLA | ||||||||
| FirstName: | JYOTHI | ||||||||
| MiddleName: | DYAVANAPALLI | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GUDLA | ||||||||
| OtherFirstName: | JYOTHI | ||||||||
| OtherMiddleName: | D | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7123 MOSSY OAKS AVE NW | ||||||||
| Address2: | |||||||||
| City: | MASSILLON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446469107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306220207 | ||||||||
| FaxNumber: | 3308323499 | ||||||||
| Practice Location | |||||||||
| Address1: | 4808 MUNSON ST NW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447183613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306220207 | ||||||||
| FaxNumber: | 3308323499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 08/24/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35-083145 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 35.083145 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 35-083145 | OH | N | Allopathic & Osteopathic Physicians | Hospitalist | 207RG0300X | 35.083145 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
No ID Information.