Provider Demographics
NPI:1013395250
Name:GANGADHARAN NAMBIAR, GOPINATHAN
Entity Type:Individual
Prefix:
First Name:GOPINATHAN
Middle Name:
Last Name:GANGADHARAN NAMBIAR
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 1:2901 OLD JACKSONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-7437
Mailing Address - Country:US
Mailing Address - Phone:217-698-9722
Mailing Address - Fax:217-391-0392
Practice Address - Street 1:2901 OLD JACKSONVILLE RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-7437
Practice Address - Country:US
Practice Address - Phone:217-698-9722
Practice Address - Fax:217-391-0392
Is Sole Proprietor?:No
Enumeration Date:2015-05-07
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036142874208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics