Provider Demographics
NPI:1134116791
Name:GURUSWAMY, GOPAL (MD)
Entity Type:Individual
Prefix:
First Name:GOPAL
Middle Name:
Last Name:GURUSWAMY
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 1:701 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-5930
Mailing Address - Country:US
Mailing Address - Phone:301-609-4000
Mailing Address - Fax:301-609-4410
Practice Address - Street 1:701 CHARLES ST
Practice Address - Street 2:
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-5930
Practice Address - Country:US
Practice Address - Phone:301-609-4000
Practice Address - Fax:301-609-4410
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD001005208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD01222Medicare UPIN