Provider Demographics
NPI:1083661805
Name:GUNDAMRAJ, NARASIMHA R (MD)
Entity Type:Individual
Prefix:
First Name:NARASIMHA
Middle Name:R
Last Name:GUNDAMRAJ
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 1:1540 LAKE LANSING RD
Mailing Address - Street 2:SUITE G06
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-3756
Mailing Address - Country:US
Mailing Address - Phone:517-482-7246
Mailing Address - Fax:517-484-7377
Practice Address - Street 1:1540 LAKE LANSING RD
Practice Address - Street 2:SUITE G06
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-3756
Practice Address - Country:US
Practice Address - Phone:517-482-7246
Practice Address - Fax:517-484-7377
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA92369207L00000X
MI4301083310207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
00A923690OtherBLUE SHIELD
CA00A923690Medicaid
CA00A923690Medicaid
CAWA92369AMedicare ID - Type Unspecified