Provider Demographics
NPI:1053752832
Name:IRAWAN, GUNARDI NYOTO (MD)
Entity type:Individual
Prefix:
First Name:GUNARDI
Middle Name:NYOTO
Last Name:IRAWAN
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 1:171 MAIN ST STE 203B
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01721-1187
Mailing Address - Country:US
Mailing Address - Phone:508-881-3029
Mailing Address - Fax:508-881-1752
Practice Address - Street 1:162 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTHBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01532-1930
Practice Address - Country:US
Practice Address - Phone:508-393-1307
Practice Address - Fax:508-393-2824
Is Sole Proprietor?:No
Enumeration Date:2013-07-09
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA269613207R00000X
ORMD214386207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine