Provider Demographics
NPI:1467866129
Name:GOTTUMUKKALA, RAVI VARMA (MD)
Entity Type:Individual
Prefix:
First Name:RAVI
Middle Name:VARMA
Last Name:GOTTUMUKKALA
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 1:4 LONGFELLOW PL APT 2009
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2817
Mailing Address - Country:US
Mailing Address - Phone:630-291-9085
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST.
Practice Address - Street 2:RADIOLOGY
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:630-291-9085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-19
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2732312085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology