Provider Demographics
NPI:1356414890
Name:GUNNALA, VIKRAM (DO)
Entity type:Individual
Prefix:
First Name:VIKRAM
Middle Name:
Last Name:GUNNALA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11116 MEDICAL CAMPUS RD
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-6710
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11116 MEDICAL CAMPUS RD
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-6710
Practice Address - Country:US
Practice Address - Phone:301-790-8804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH80041207R00000X
IL036-111820207R00000X
IN02003411A207R00000X
IL036111820208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000612723OtherBCBS
IN200930590Medicaid
ILK49007Medicare PIN
IN941050BBBBMedicare PIN
IN200930590Medicaid
INP00725759Medicare PIN