Provider Demographics
NPI:1003887381
Name:GUNDUMALLA, GOPI K (MD)
Entity type:Individual
Prefix:
First Name:GOPI
Middle Name:K
Last Name:GUNDUMALLA
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 1:4439 STATE ROUTE 159
Mailing Address - Street 2:STE 204
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-8207
Mailing Address - Country:US
Mailing Address - Phone:740-779-8728
Mailing Address - Fax:740-779-8729
Practice Address - Street 1:4439 STATE ROUTE 159
Practice Address - Street 2:STE 204
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-8207
Practice Address - Country:US
Practice Address - Phone:740-779-8728
Practice Address - Fax:740-779-8729
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36942207RN0300X
OH35.094522207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810016457Medicaid
KY64053077Medicaid
OH3011314Medicaid
WV3810016457Medicaid
KY0501602Medicare ID - Type Unspecified
OHGU4283112Medicare PIN