Provider Demographics
NPI:1629855424
Name:GORANTLA, GOPI KRISHN
Entity Type:Individual
Prefix:
First Name:GOPI
Middle Name:KRISHN
Last Name:GORANTLA
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 1:1653 NORDLAND DR
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-7190
Mailing Address - Country:US
Mailing Address - Phone:317-513-2886
Mailing Address - Fax:
Practice Address - Street 1:6525 E 82ND ST STE 103
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-1545
Practice Address - Country:US
Practice Address - Phone:317-348-4949
Practice Address - Fax:317-537-2089
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05009128A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty