Provider Demographics
NPI:1578798393
Name:PENDURTI, GOPICHAND (MD)
Entity Type:Individual
Prefix:DR
First Name:GOPICHAND
Middle Name:
Last Name:PENDURTI
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 1:902 N RIVERSIDE RD
Mailing Address - Street 2:STE 200
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64507-2518
Mailing Address - Country:US
Mailing Address - Phone:816-271-1301
Mailing Address - Fax:816-271-1302
Practice Address - Street 1:902 N RIVERSIDE RD
Practice Address - Street 2:STE 200
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64507-2518
Practice Address - Country:US
Practice Address - Phone:816-271-1301
Practice Address - Fax:816-271-1302
Is Sole Proprietor?:No
Enumeration Date:2009-05-22
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY279764207RH0003X
MO2016023070207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP01795280OtherRR MEDICARE
MO1578798393Medicaid
IA1578798393Medicaid
KS201149740AMedicaid
MOMA4170121Medicare PIN
MO701000347Medicare PIN