Provider Demographics
NPI:1407877434
Name:GOVONLU, CAMERON M (MD)
Entity Type:Individual
Prefix:
First Name:CAMERON
Middle Name:M
Last Name:GOVONLU
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 1:1244 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:RAYNHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02767-1973
Mailing Address - Country:US
Mailing Address - Phone:508-824-0035
Mailing Address - Fax:508-823-6127
Practice Address - Street 1:1244 BROADWAY
Practice Address - Street 2:
Practice Address - City:RAYNHAM
Practice Address - State:MA
Practice Address - Zip Code:02767-1973
Practice Address - Country:US
Practice Address - Phone:508-824-0035
Practice Address - Fax:508-823-6127
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA47135207L00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0176753Medicaid
MAA40782Medicare UPIN
MA0176753Medicaid