Provider Demographics
NPI:1992732663
Name:GOPALAKRISHNAN, PRABHAKARAN P (MD)
Entity type:Individual
Prefix:DR
First Name:PRABHAKARAN
Middle Name:P
Last Name:GOPALAKRISHNAN
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 1:1500 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4917
Mailing Address - Country:US
Mailing Address - Phone:817-921-3431
Mailing Address - Fax:
Practice Address - Street 1:2600 SIXTH ST SW STE 710
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44710-1702
Practice Address - Country:US
Practice Address - Phone:330-454-8076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9215207R00000X
OH35.125932207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX167626402Medicaid
TXI16036Medicare UPIN
TX8D8412Medicare ID - Type Unspecified