Provider Demographics
NPI:1700383569
Name:GANNAMANI, GOWTHAM (MD)
Entity Type:Individual
Prefix:
First Name:GOWTHAM
Middle Name:
Last Name:GANNAMANI
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 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:727 SE MAIN ST STE 340
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-3249
Practice Address - Country:US
Practice Address - Phone:864-455-2888
Practice Address - Fax:864-455-2885
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC86254207RE0101X
SCLL86254207RE0101X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism