Provider Demographics
NPI:1104866052
Name:GOPALAN, SRIKUMAR (MD)
Entity Type:Individual
Prefix:
First Name:SRIKUMAR
Middle Name:
Last Name:GOPALAN
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:PO BOX 12666
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24027-2666
Mailing Address - Country:US
Mailing Address - Phone:276-679-9666
Mailing Address - Fax:
Practice Address - Street 1:101 15TH ST NW
Practice Address - Street 2:
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273-1615
Practice Address - Country:US
Practice Address - Phone:276-328-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010362242085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007238151Medicaid
B05307Medicare UPIN
VA300000270Medicare PIN