Provider Demographics
NPI:1316106305
Name:GONGIREDDY, SRINIVAS V (MD)
Entity type:Individual
Prefix:
First Name:SRINIVAS
Middle Name:V
Last Name:GONGIREDDY
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 1:1034 KENNEDY BLVD
Mailing Address - Street 2:B-3
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-2022
Mailing Address - Country:US
Mailing Address - Phone:201-988-4534
Mailing Address - Fax:
Practice Address - Street 1:355 GRAND ST
Practice Address - Street 2:3 EAST , DEPT OF MEDICINE
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-4321
Practice Address - Country:US
Practice Address - Phone:201-915-2430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-04
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08416400207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0209139Medicaid
NJ149754ZDDHMedicare PIN