Basic Information
| Provider Information | |||||||||
| NPI: | 1033141692 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUMMADI | ||||||||
| FirstName: | BHARAT | ||||||||
| MiddleName: | KUMAR | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 43667 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322033667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047200599 | ||||||||
| FaxNumber: | 9043764036 | ||||||||
| Practice Location | |||||||||
| Address1: | 14534 OLD SAINT AUGUSTINE RD STE 3420 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322582616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044938001 | ||||||||
| FaxNumber: | 9043380852 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 03/31/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | ME96186 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207UN0901X | ME96186 | FL | N | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology | 207RI0011X | ME96186 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | P01191148 | 01 | FL | RAILROAD MEDICARE | OTHER | 2757036-00 | 05 | FL | MEDICAID | 003125740A | 05 | GA | MEDICAID |