Provider Demographics
NPI:1760410823
Name:VASUDEVAN, GOPIKRISHNAN (MD)
Entity Type:Individual
Prefix:
First Name:GOPIKRISHNAN
Middle Name:
Last Name:VASUDEVAN
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 1:816 22ND AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845-2206
Mailing Address - Country:US
Mailing Address - Phone:308-865-2263
Mailing Address - Fax:308-865-2541
Practice Address - Street 1:816 22ND AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68845-2206
Practice Address - Country:US
Practice Address - Phone:308-865-2263
Practice Address - Fax:308-865-2541
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE31491207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK40052217Medicare ID - Type Unspecified
OKF98133Medicare UPIN