Provider Demographics
NPI:1376700930
Name:GOPALAN, PUSHKAS (MD)
Entity Type:Individual
Prefix:DR
First Name:PUSHKAS
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 699
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-0699
Mailing Address - Country:US
Mailing Address - Phone:423-439-7280
Mailing Address - Fax:
Practice Address - Street 1:325 N STATE OF FRANKLIN RD FL 2
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6092
Practice Address - Country:US
Practice Address - Phone:423-439-7280
Practice Address - Fax:423-439-8110
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD45212207R00000X
TN45212208M00000X
VA0101255959207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVD085BMedicare PIN
TN103I111948Medicare PIN