Provider Demographics
NPI:1073508693
Name:GOPAL, MALAVALLI (MD)
Entity Type:Individual
Prefix:
First Name:MALAVALLI
Middle Name:
Last Name:GOPAL
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 1:9 NORTHEASTERN BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:NH
Mailing Address - Zip Code:03079-1996
Mailing Address - Country:US
Mailing Address - Phone:800-927-0002
Mailing Address - Fax:
Practice Address - Street 1:1153 CENTRE ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130-3446
Practice Address - Country:US
Practice Address - Phone:617-522-6010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA38054207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2065053Medicaid
MA2065053Medicaid
MAC18102Medicare PIN