Provider Demographics
NPI:1124259536
Name:NEOGERIATRICS
Entity type:Organization
Organization Name:NEOGERIATRICS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JYOTHI
Authorized Official - Middle Name:DYAVANAPALLI
Authorized Official - Last Name:GUDLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-830-8666
Mailing Address - Street 1:4808 MUNSON ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-3613
Mailing Address - Country:US
Mailing Address - Phone:330-830-8666
Mailing Address - Fax:330-832-3499
Practice Address - Street 1:4808 MUNSON ST NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718
Practice Address - Country:US
Practice Address - Phone:330-830-8666
Practice Address - Fax:330-832-3499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-03
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-083145207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2940956Medicaid