Provider Demographics
NPI:1902045271
Name:PENMETSA, GOPI KRISHNA RAJU (MD)
Entity Type:Individual
Prefix:DR
First Name:GOPI
Middle Name:KRISHNA RAJU
Last Name:PENMETSA
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 1:2096 E RAINBOW POINT DR
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1721
Mailing Address - Country:US
Mailing Address - Phone:801-803-8728
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY HOSPITAL
Practice Address - Street 2:50 NORTH MEDICAL DRIVE
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0001
Practice Address - Country:US
Practice Address - Phone:801-803-8728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-10
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7478485-1205207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
0622596OtherUNIVERSITY ID