Provider Demographics
NPI:1497378640
Name:KOORAPATI, GOWTHAMI (MD)
Entity Type:Individual
Prefix:MRS
First Name:GOWTHAMI
Middle Name:
Last Name:KOORAPATI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 ROSS LN
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050
Mailing Address - Country:US
Mailing Address - Phone:845-480-6275
Mailing Address - Fax:
Practice Address - Street 1:3421 W 9TH ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-5401
Practice Address - Country:US
Practice Address - Phone:319-272-8349
Practice Address - Fax:319-272-8355
Is Sole Proprietor?:No
Enumeration Date:2020-05-22
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-50633207R00000X
IL61328084955K207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine