Provider Demographics
NPI:1710628573
Name:MADDINENI, GAUTAM (MBBS)
Entity type:Individual
Prefix:
First Name:GAUTAM
Middle Name:
Last Name:MADDINENI
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7710 MERCY ROAD, SUITE 202
Mailing Address - Street 2:CU DEPARTMENT OF GASTROENTEROLOGY
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-2353
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7710 MERCY ROAD, SUITE 202
Practice Address - Street 2:CU DEPARTMENT OF GASTROENTEROLOGY
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-2353
Practice Address - Country:US
Practice Address - Phone:402-280-4191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2025-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
NE10191207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program