Provider Demographics
NPI:1629386701
Name:HEBBALMATH, GOUTHAM (MD)
Entity Type:Individual
Prefix:
First Name:GOUTHAM
Middle Name:
Last Name:HEBBALMATH
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 1:57 SUMMIT DR
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-2746
Mailing Address - Country:US
Mailing Address - Phone:606-528-9700
Mailing Address - Fax:606-528-8423
Practice Address - Street 1:57 SUMMIT DR
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-2746
Practice Address - Country:US
Practice Address - Phone:606-528-9700
Practice Address - Fax:606-528-8423
Is Sole Proprietor?:No
Enumeration Date:2010-09-22
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY46189208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100256410Medicaid
KYK087780Medicare PIN