Provider Demographics
NPI:1467458034
Name:MAJMUNDAR, GOPAL R (MD)
Entity Type:Individual
Prefix:
First Name:GOPAL
Middle Name:R
Last Name:MAJMUNDAR
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 1:11217 MAIN STREET
Mailing Address - Street 2:PO BOX 828
Mailing Address - City:MARTIN
Mailing Address - State:KY
Mailing Address - Zip Code:41649-0828
Mailing Address - Country:US
Mailing Address - Phone:606-886-1714
Mailing Address - Fax:606-285-9484
Practice Address - Street 1:11217 MAIN STREET
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:KY
Practice Address - Zip Code:41649-0828
Practice Address - Country:US
Practice Address - Phone:606-285-9000
Practice Address - Fax:606-285-9484
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2012-10-12
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-23
Provider Licenses
StateLicense IDTaxonomies
KY19452207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000068352OtherBLUCROSS BLUE SHIELD
KY000000000827OtherCHA
KY1247781OtherUMWA
KY64194525Medicaid
KY209332OtherBLACK LUNG
KY000000068352OtherBLUCROSS BLUE SHIELD
KY209332OtherBLACK LUNG