Provider Demographics
NPI:1801896097
Name:RAMAKRISHNA, GAUTAM (MD)
Entity type:Individual
Prefix:
First Name:GAUTAM
Middle Name:
Last Name:RAMAKRISHNA
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 1:2901 TELESTAR CT.
Mailing Address - Street 2:#300
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-1263
Mailing Address - Country:US
Mailing Address - Phone:703-591-1688
Mailing Address - Fax:703-591-1445
Practice Address - Street 1:3580 JOSEPH SIEWICK DR STE 305
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1764
Practice Address - Country:US
Practice Address - Phone:703-648-3266
Practice Address - Fax:703-648-3264
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101237937207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC037554300Medicaid
VA1801896097Medicaid
MD407344400Medicaid
DCP00230443OtherRAILROAD MEDICARE DC #
MD407344400Medicaid
DC017436C42Medicare PIN
VA007952T55Medicare PIN
DC037554300Medicaid
MD407344400Medicaid
VA007952T55Medicare PIN
DC017436C42Medicare PIN