Provider Demographics
NPI:1396373502
Name:GORUKANTI, SRECHARAN SHIVA (MD)
Entity Type:Individual
Prefix:
First Name:SRECHARAN
Middle Name:SHIVA
Last Name:GORUKANTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1402 S GRAND BLVD # 12
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1004
Mailing Address - Country:US
Mailing Address - Phone:314-577-8762
Mailing Address - Fax:314-268-5108
Practice Address - Street 1:1959 NE PACIFIC ST # BB-928
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-2540
Practice Address - Country:US
Practice Address - Phone:479-629-4490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-01
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61158152208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation