Provider Demographics
NPI:1093883316
Name:VENUGOPAL, NARASIMHALOO (MD)
Entity Type:Individual
Prefix:
First Name:NARASIMHALOO
Middle Name:
Last Name:VENUGOPAL
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 1:76 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360-4851
Mailing Address - Country:US
Mailing Address - Phone:856-205-1112
Mailing Address - Fax:856-205-1114
Practice Address - Street 1:1100 E CHESTNUT AVE
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-5002
Practice Address - Country:US
Practice Address - Phone:856-696-0108
Practice Address - Fax:856-696-0188
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02825000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2875501Medicaid
NJ2875501Medicaid
NJ2875501Medicaid
556620Medicare ID - Type Unspecified