Provider Demographics
NPI:1851302137
Name:DIVAKARA MURTHY, GOWDARA (MD)
Entity Type:Individual
Prefix:
First Name:GOWDARA
Middle Name:
Last Name:DIVAKARA MURTHY
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 1:711 TROY SCHENECTADY RD STE 203
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2461
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:2546 BALLTOWN RD
Practice Address - Street 2:SUITE 200
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12309-1079
Practice Address - Country:US
Practice Address - Phone:518-374-1444
Practice Address - Fax:518-374-0491
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208468207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03299543Medicaid
NY7795243OtherAETNA
NY781CB1OtherEMPIRE BLUECROSS BLUESHIELD
NY130712000045OtherFIDELIS
NYJ400092467Medicare PIN
NYJ400092466Medicare PIN
NYJ400039948Medicare PIN