Provider Demographics
NPI:1235183450
Name:GOPALAKRISHNAN, GEETHA (MD)
Entity Type:Individual
Prefix:
First Name:GEETHA
Middle Name:
Last Name:GOPALAKRISHNAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 ELM ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4626
Mailing Address - Country:US
Mailing Address - Phone:401-649-4090
Mailing Address - Fax:401-649-4091
Practice Address - Street 1:375 WAMPANOAG TRL STE 202B
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:RI
Practice Address - Zip Code:02915-2234
Practice Address - Country:US
Practice Address - Phone:401-649-4090
Practice Address - Fax:401-649-4091
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD10756207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9023829Medicaid
RI9023829Medicaid