Provider Demographics
NPI:1790049013
Name:GANGAVALLI, ANUP KRISHNA (MD)
Entity Type:Individual
Prefix:
First Name:ANUP
Middle Name:KRISHNA
Last Name:GANGAVALLI
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:P. O. BOX 715868
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19171-4067
Mailing Address - Country:US
Mailing Address - Phone:804-215-3063
Mailing Address - Fax:
Practice Address - Street 1:5899 BREMO ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226
Practice Address - Country:US
Practice Address - Phone:804-288-8512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-02
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT202570207X00000X
FLME136492207X00000X
VA0101272652207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery