Provider Demographics
NPI:1588226229
Name:TALLURI, GOUTHAM
Entity type:Individual
Prefix:DR
First Name:GOUTHAM
Middle Name:
Last Name:TALLURI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 4TH ST STE 30105
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-8420
Mailing Address - Country:US
Mailing Address - Phone:318-483-1961
Mailing Address - Fax:318-483-1964
Practice Address - Street 1:201 4TH ST STE 5A
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-8421
Practice Address - Country:US
Practice Address - Phone:318-483-1961
Practice Address - Fax:318-483-1964
Is Sole Proprietor?:No
Enumeration Date:2019-07-02
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA343630207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology