Provider Demographics
NPI:1720041247
Name:GOPAL, VIKRAM DEVEGOWDA (MD)
Entity Type:Individual
Prefix:DR
First Name:VIKRAM
Middle Name:DEVEGOWDA
Last Name:GOPAL
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 1:4800 BELFORT ROAD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256
Mailing Address - Country:US
Mailing Address - Phone:904-398-3262
Mailing Address - Fax:904-265-4807
Practice Address - Street 1:4800 BELFORT ROAD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256
Practice Address - Country:US
Practice Address - Phone:904-398-7205
Practice Address - Fax:904-396-4047
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87348207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL275758300Medicaid
FL44029ZMedicare PIN