Provider Demographics
NPI:1003108796
Name:VUDATHU, RAMAGOPAL
Entity Type:Individual
Prefix:
First Name:RAMAGOPAL
Middle Name:
Last Name:VUDATHU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 HORIZON BLVD
Mailing Address - Street 2:
Mailing Address - City:TREVOSE
Mailing Address - State:PA
Mailing Address - Zip Code:19053-4968
Mailing Address - Country:US
Mailing Address - Phone:215-494-9403
Mailing Address - Fax:215-357-2129
Practice Address - Street 1:3800 HORIZON BLVD STE 103
Practice Address - Street 2:
Practice Address - City:TREVOSE
Practice Address - State:PA
Practice Address - Zip Code:19053-4968
Practice Address - Country:US
Practice Address - Phone:215-494-9403
Practice Address - Fax:215-357-2129
Is Sole Proprietor?:No
Enumeration Date:2011-05-12
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0007322183500000X
PARP450406183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist