Provider Demographics
NPI:1063671600
Name:GOTUR, DEEPA BANGALORE (MD)
Entity Type:Individual
Prefix:DR
First Name:DEEPA
Middle Name:BANGALORE
Last Name:GOTUR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:PRAKASH DEEPA
Other - Middle Name:
Other - Last Name:BANGALORE SURYA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6565 FANNIN ST
Mailing Address - Street 2:F270
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2703
Mailing Address - Country:US
Mailing Address - Phone:713-441-3020
Mailing Address - Fax:
Practice Address - Street 1:6565 FANNIN ST
Practice Address - Street 2:F270
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2703
Practice Address - Country:US
Practice Address - Phone:713-441-3020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY242789207R00000X
TXN0628207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX201387201Medicaid
TX8BQ747OtherBLUE CROSS BLUE SHIELD
TXP01123925OtherRR MEDICARE
TX201387203Medicaid
TXP01402887OtherRR MEDICARE
TX201387202Medicaid
TX8EE524OtherBLUE CROSS BLUE SHIELD
TX8L9196Medicare PIN
TX201387201Medicaid
TX201387202Medicaid