Provider Demographics
NPI:1053316547
Name:GUDIMETLA, SREENIVAS (MD)
Entity type:Individual
Prefix:DR
First Name:SREENIVAS
Middle Name:
Last Name:GUDIMETLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 RIVER NORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:STEPHENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76401-1803
Mailing Address - Country:US
Mailing Address - Phone:254-968-6051
Mailing Address - Fax:254-968-4950
Practice Address - Street 1:150 RIVER NORTH BLVD
Practice Address - Street 2:
Practice Address - City:STEPHENVILLE
Practice Address - State:TX
Practice Address - Zip Code:76401-1803
Practice Address - Country:US
Practice Address - Phone:254-968-6051
Practice Address - Fax:254-968-4950
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ2041207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX89790VOtherBLUE CROSS
TX89755JOtherBCBS PROVIDER NUMBER
P00074958OtherRAIL ROAD MEDICARE
TX2749061002OtherCIGNA PROVIDER NUMBER
TX060057347OtherRAILROAD MEDICARE PROV NO
TX5673038OtherAETNA PROVIDER NUMBER
TX125365003Medicaid
TX193006902OtherUNITED HEALTHCARE PROV NO
TX060057347OtherRAILROAD MEDICARE PROV NO
TXF83527Medicare UPIN
TX125365003Medicaid