Provider Demographics
NPI:1780665398
Name:MURTY, GANNAVARAPU V (MD)
Entity Type:Individual
Prefix:
First Name:GANNAVARAPU
Middle Name:V
Last Name:MURTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:G V N
Other - Middle Name:
Other - Last Name:MURTY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:603 N.E. 2ND ST.
Mailing Address - Street 2:
Mailing Address - City:ANTLERS
Mailing Address - State:OK
Mailing Address - Zip Code:74523
Mailing Address - Country:US
Mailing Address - Phone:580-298-3351
Mailing Address - Fax:580-298-3803
Practice Address - Street 1:1201 E JACKSON ST
Practice Address - Street 2:HUGO RURAL HEALTH CLINIC
Practice Address - City:HUGO
Practice Address - State:OK
Practice Address - Zip Code:74743
Practice Address - Country:US
Practice Address - Phone:580-326-6423
Practice Address - Fax:580-326-3660
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2012-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13831207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100521610BMedicaid
OKD91219Medicare UPIN