Provider Demographics
NPI:1942338330
Name:GURUBHAGAVATULA, RAO RAMAKRISHNA (MD)
Entity Type:Individual
Prefix:DR
First Name:RAO
Middle Name:RAMAKRISHNA
Last Name:GURUBHAGAVATULA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:G.
Other - Middle Name:R
Other - Last Name:RAO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3128 HARFORD RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-3114
Mailing Address - Country:US
Mailing Address - Phone:410-235-2022
Mailing Address - Fax:
Practice Address - Street 1:3128 HARFORD RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-3114
Practice Address - Country:US
Practice Address - Phone:410-235-2022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2009-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD17004207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD187841700Medicaid
MD6976Medicare ID - Type Unspecified