Provider Demographics
NPI:1053582478
Name:JYOTHI GADDE MD PA
Entity type:Organization
Organization Name:JYOTHI GADDE MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JYOTHI
Authorized Official - Middle Name:
Authorized Official - Last Name:GADDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-428-1715
Mailing Address - Street 1:493 BLACKWELL ROAD
Mailing Address - Street 2:STE 305
Mailing Address - City:WARRENTON
Mailing Address - State:VA
Mailing Address - Zip Code:20186-2628
Mailing Address - Country:US
Mailing Address - Phone:540-428-1715
Mailing Address - Fax:540-428-1716
Practice Address - Street 1:3700 JOSEPH SIEWICK DR
Practice Address - Street 2:STE 304
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1744
Practice Address - Country:US
Practice Address - Phone:703-648-0015
Practice Address - Fax:703-648-0047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101056351174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007603436Medicaid
DC156315Medicare PIN
VA007603436Medicaid