Provider Demographics
NPI:1861629966
Name:GUJJULA, RAJESH (MD)
Entity type:Individual
Prefix:DR
First Name:RAJESH
Middle Name:
Last Name:GUJJULA
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 1:5750A SOUTHLAND DR
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36693-3316
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13833 TAPIA AVE
Practice Address - Street 2:
Practice Address - City:BAYOU LA BATRE
Practice Address - State:AL
Practice Address - Zip Code:36509-2515
Practice Address - Country:US
Practice Address - Phone:251-824-8320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA205576208M00000X
ALMD.41161207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1929743Medicaid
267320YJBUMedicare PIN