Provider Demographics
NPI:1891137485
Name:LINGAMANENI, GOWTHAM ROY (MD)
Entity Type:Individual
Prefix:
First Name:GOWTHAM
Middle Name:ROY
Last Name:LINGAMANENI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:NOT APPLICABLE
Other - Middle Name:
Other - Last Name:NOT APPLICABLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:136 BARNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:24605-1165
Mailing Address - Country:US
Mailing Address - Phone:312-888-6170
Mailing Address - Fax:
Practice Address - Street 1:500 CHERRY ST
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701-3306
Practice Address - Country:US
Practice Address - Phone:304-327-1888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-23
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101267383208600000X
WV29019208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery