Basic Information
| Provider Information | |||||||||
| NPI: | 1346458767 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUNDABOLU | ||||||||
| FirstName: | BHASKAR | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 W CENTRAL AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436063834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195375111 | ||||||||
| FaxNumber: | 4195375131 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 W CENTRAL AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436063834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195375111 | ||||||||
| FaxNumber: | 4195375131 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2007 | ||||||||
| LastUpdateDate: | 02/26/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | 35088652 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 6870 | 01 | OH | PARAMOUNT | OTHER | 000000541140 | 01 | OH | ANTHEM | OTHER | 2831243 | 05 | OH | MEDICAID | 751132 | 01 | OH | BUCKEYE | OTHER | 66501560001 | 01 | OH | MEDICAL MUTUAL | OTHER | 9567063 | 01 | OH | AETNA | OTHER |