Basic Information
| Provider Information | |||||||||
| NPI: | 1417141425 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAJJELA | ||||||||
| FirstName: | HEMLATA | ||||||||
| MiddleName: | REDDY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5900 S JOHN YOUNG PKWY | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328393716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073986470 | ||||||||
| FaxNumber: | 4078946872 | ||||||||
| Practice Location | |||||||||
| Address1: | 5900 S JOHN YOUNG PKWY | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328393716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073986470 | ||||||||
| FaxNumber: | 4078946872 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2007 | ||||||||
| LastUpdateDate: | 03/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | ME114618 | FL | N | Allopathic & Osteopathic Physicians | Hospitalist | 208000000X | 13151 | NV | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | ME114618 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1417141425 | 05 | NV | MEDICAID |