Basic Information
Provider Information | |||||||||
NPI: | 1215908678 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GUDIPATI | ||||||||
FirstName: | CHALAPATHIRAO | ||||||||
MiddleName: | V | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GUDIPATI | ||||||||
OtherFirstName: | RAO | ||||||||
OtherMiddleName: | VC | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 1015 S WASHINGTON AVE | ||||||||
Address2: |   | ||||||||
City: | SAGINAW | ||||||||
State: | MI | ||||||||
PostalCode: | 486012556 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9897543000 | ||||||||
FaxNumber: | 9897551365 | ||||||||
Practice Location | |||||||||
Address1: | 1015 S WASHINGTON AVE | ||||||||
Address2: |   | ||||||||
City: | SAGINAW | ||||||||
State: | MI | ||||||||
PostalCode: | 486012556 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9897543000 | ||||||||
FaxNumber: | 9897551365 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/01/2006 | ||||||||
LastUpdateDate: | 03/29/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/29/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | 4301056478 | MI | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
ID | Type | State | Issuer | Description | 4526540 | 05 | MI |   | MEDICAID |