Provider Demographics
NPI:1740261924
Name:SRINIVASAN, GOPALAKRISHNAN (MD)
Entity type:Individual
Prefix:
First Name:GOPALAKRISHNAN
Middle Name:
Last Name:SRINIVASAN
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 1:3510 OLD WASHINGTON ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-3234
Mailing Address - Country:US
Mailing Address - Phone:301-932-5890
Mailing Address - Fax:301-645-6361
Practice Address - Street 1:3510 OLD WASHINGTON ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-3234
Practice Address - Country:US
Practice Address - Phone:301-932-5890
Practice Address - Fax:301-645-6361
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0046345207RC0000X
VA101055162207RC0000X
DCMD32794207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD213500100Medicaid
G39828Medicare UPIN
MD005446S66Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE #
MD894SMedicare PIN
DC000265H15Medicare PIN