Provider Demographics
NPI:1881750073
Name:TATAMBHOTLA, GOPAL (MD)
Entity type:Individual
Prefix:DR
First Name:GOPAL
Middle Name:
Last Name:TATAMBHOTLA
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:PO BOX 700
Mailing Address - Street 2:
Mailing Address - City:LECANTO
Mailing Address - State:FL
Mailing Address - Zip Code:34460-0700
Mailing Address - Country:US
Mailing Address - Phone:352-527-9500
Mailing Address - Fax:352-527-7215
Practice Address - Street 1:534 N LECANTO HWY
Practice Address - Street 2:
Practice Address - City:LECANTO
Practice Address - State:FL
Practice Address - Zip Code:34461-8547
Practice Address - Country:US
Practice Address - Phone:352-527-9500
Practice Address - Fax:352-527-7215
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME728572084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252002800Medicaid
FL252002800Medicaid
FL41452ZMedicare PIN