Basic Information
| Provider Information | |||||||||
| NPI: | 1073850251 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GURUGURI | ||||||||
| FirstName: | PRATHIMA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MBBS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26666 | ||||||||
| Address2: | PHS PROVIDER ENROLLMENT | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871256666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059236770 | ||||||||
| FaxNumber: | 5059235354 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 CENTRAL AVE SE | ||||||||
| Address2: | 4TH FLOOR B | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057246124 | ||||||||
| FaxNumber: | 5057246125 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2013 | ||||||||
| LastUpdateDate: | 03/04/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | NM | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | MD2014-0802 | NM | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 69277851 | 05 | NM | MEDICAID |