Provider Demographics
NPI:1477555316
Name:GODISHALA, RAMAMURTHY (MD)
Entity Type:Individual
Prefix:
First Name:RAMAMURTHY
Middle Name:
Last Name:GODISHALA
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 1:281 GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-1421
Mailing Address - Country:US
Mailing Address - Phone:315-253-4459
Mailing Address - Fax:315-255-2984
Practice Address - Street 1:281 GRANT AVE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-1421
Practice Address - Country:US
Practice Address - Phone:315-253-4459
Practice Address - Fax:315-255-2984
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY161158207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0095926Medicaid
NY55122CMedicare ID - Type Unspecified
NY0095926Medicaid