Provider Demographics
NPI:1578518031
Name:RAO, GORANTLA SUBBA (MD)
Entity Type:Individual
Prefix:DR
First Name:GORANTLA
Middle Name:SUBBA
Last Name:RAO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:G.S.
Other - Middle Name:
Other - Last Name:RAO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1425 WEATHERLY RD SE
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35803-1178
Mailing Address - Country:US
Mailing Address - Phone:256-881-1111
Mailing Address - Fax:256-882-1410
Practice Address - Street 1:1425 WEATHERLY RD SE
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35803-1178
Practice Address - Country:US
Practice Address - Phone:256-881-1111
Practice Address - Fax:256-882-1410
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL8243207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000060906Medicaid
AL4036876OtherAETNA
AL000060906Medicaid
AL000060906Medicare ID - Type Unspecified