Provider Demographics
NPI:1962763219
Name:CHURUKANTI, GAUTHAMI REDDY (MD)
Entity type:Individual
Prefix:DR
First Name:GAUTHAMI
Middle Name:REDDY
Last Name:CHURUKANTI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2350 FREEDOM WAY STE 102
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-8265
Mailing Address - Country:US
Mailing Address - Phone:717-741-9536
Mailing Address - Fax:717-741-5509
Practice Address - Street 1:101 NICOLLS RD # HSCT9040
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8265
Practice Address - Country:US
Practice Address - Phone:631-444-2348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-04
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD460958174400000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist