Basic Information
Provider Information
NPI: 1003142738
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GELLI
FirstName: SREEDHAR
MiddleName:  
NamePrefix: DR.
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: P.O. BOX 2147
Address2:  
City: FORT MYERS
State: FL
PostalCode: 339022147
CountryCode: US
TelephoneNumber: 2394241449
FaxNumber:  
Practice Location
Address1: 9981 S HEALTHPARK DR
Address2:  
City: FORT MYERS
State: FL
PostalCode: 339083618
CountryCode: US
TelephoneNumber: 2393432052
FaxNumber: 2393435348
Other Information
ProviderEnumerationDate: 10/30/2009
LastUpdateDate: 11/11/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208M00000XME106612FLY Allopathic & Osteopathic PhysiciansHospitalist 

ID Information
IDTypeStateIssuerDescription
00249440005FL MEDICAID


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