Provider Demographics
NPI:1972891000
Name:SREEPATI, GOURI (MD)
Entity Type:Individual
Prefix:
First Name:GOURI
Middle Name:
Last Name:SREEPATI
Suffix:
Gender:F
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-468-0144
Mailing Address - Fax:239-343-4051
Practice Address - Street 1:23450 VIA COCONUT PT
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:34135-1877
Practice Address - Country:US
Practice Address - Phone:239-468-0144
Practice Address - Fax:239-343-4051
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME146160207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107092700Medicaid