Provider Demographics
NPI:1952399354
Name:GOVINDAIAH, GORANTLA (MD)
Entity Type:Individual
Prefix:DR
First Name:GORANTLA
Middle Name:
Last Name:GOVINDAIAH
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 1:4366 KENNEDY DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:EAST MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61244-4202
Mailing Address - Country:US
Mailing Address - Phone:309-796-1510
Mailing Address - Fax:309-796-1565
Practice Address - Street 1:4366 KENNEDY DR
Practice Address - Street 2:SUITE B
Practice Address - City:EAST MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61244-4202
Practice Address - Country:US
Practice Address - Phone:309-796-1510
Practice Address - Fax:309-796-1565
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL03649003174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
263500Medicare ID - Type Unspecified
C38530Medicare UPIN