Basic Information
Provider Information | |||||||||
NPI: | 1821364498 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GUTTA | ||||||||
FirstName: | SATYA | ||||||||
MiddleName: | KISHORE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4656 W JEFFERSON BLVD STE 201 | ||||||||
Address2: |   | ||||||||
City: | FORT WAYNE | ||||||||
State: | IN | ||||||||
PostalCode: | 468046857 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 8701 W WATERTOWN PLANK RD | ||||||||
Address2: | MEDICAL COLLEGE OF WISCONSIN AFFILIATED HOSPITALS PROGR | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 532263548 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4149558998 | ||||||||
FaxNumber: | 4149556299 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/28/2012 | ||||||||
LastUpdateDate: | 02/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/18/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084A0401X | 01086475A | IN | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine | 2084P0805X | 61391 | WI | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry | 208D00000X | 60291 | WI | N |   | Allopathic & Osteopathic Physicians | General Practice |   | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 2084P0800X | 01086475A | IN | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.