Provider Demographics
NPI:1962494583
Name:KORRAPATI, GOVARDHANA ROA (MD)
Entity Type:Individual
Prefix:DR
First Name:GOVARDHANA
Middle Name:ROA
Last Name:KORRAPATI
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 1:301 PERRY ST
Mailing Address - Street 2:
Mailing Address - City:FOSTORIA
Mailing Address - State:OH
Mailing Address - Zip Code:44830-2149
Mailing Address - Country:US
Mailing Address - Phone:419-435-9241
Mailing Address - Fax:
Practice Address - Street 1:301 PERRY ST
Practice Address - Street 2:
Practice Address - City:FOSTORIA
Practice Address - State:OH
Practice Address - Zip Code:44830-2149
Practice Address - Country:US
Practice Address - Phone:419-435-9241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-19
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35046069207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0503543Medicare PIN
OHA80176Medicare UPIN
OHA80176Medicare UPIN